However, genetics cannot account for the increase in overweight observed in the U. population over the past two decades. Rather, the behavioral and environmental factors that conspire to induce individuals to engage in too little physical activity and eat too much relative to their energy expenditure must take most of the blame.

It is these factors that are the target of weight-management strategies. This chapter reviews the efficacy and safety of strategies for weight loss, as well as the combinations of strategies that appear to be associated with successful loss.

In addition, the elements of successful weight maintenance also will be reviewed since the difficulty in maintaining weight loss may contribute to the overweight problem. A brief discussion of public policy measures that may help prevent overweight and assist those who are trying to lose weight or maintain weight loss is also included.

Increased physical activity is an essential component of a comprehensive weight-reduction strategy for overweight adults who are otherwise healthy.

One of the best predictors of success in the long-term management of overweight and obesity is the ability to develop and sustain an exercise program Jakicic et al.

The availability of exercise facilities at military bases can reinforce exercise and fitness programs that are necessary to meet the services' physical readiness needs generally, and for weight management specifically.

For a given individual, the intensity, duration, frequency, and type of physical activity will depend on existing medical conditions, degree of previous activity, physical limitations, and individual preferences. Referral for additional professional evaluation may be appropriate, especially for individuals with more than one of the above extenuating factors.

The benefits of physical activity see Table are significant and occur even in the absence of weight loss Blair, ; Kesaniemi et al.

It has been shown that one of the benefits, an increase in high-density lipoproteins, can be achieved with a threshold level of aerobic exercise of 10 to 11 hours per month. For previously sedentary individuals, a slow progression in physical activity has been recommended so that 30 minutes of exercise daily is achieved after several weeks of gradual build-up.

This may also apply to some military personnel, especially new recruits or reservists recalled to active duty who may be entering service from previously very sedentary lifestyles.

For that purpose, a weekly goal of 2, to 3, kcal of added activity may be necessary Klem et al. Thus, mental preparation for the amount of activity necessary to maintain weight loss must begin while losing weight Brownell, For many individuals, changing activity levels is perceived as more unpleasant than changing dietary habits.

However, over an month period, individuals who performed short bouts of physical activity did not experience improvements in long-term weight loss, cardiorespiratory fitness, or physical activity participation in comparison with those who performed longer bouts of exercise.

Some evidence suggests that home exercise equipment e. In addition, individual preferences are paramount considerations in choices of activity.

When strength training or resistance exercise is combined with aerobic activity, long-term results may be better than those with aerobics alone Poirier and Despres, ; Sothern et al. Because strength training tends to build muscle, loss of lean body mass may be minimized and the relative loss of body fat may be increased.

An added benefit is the attenuation of the decrease in resting metabolic rate associated with weight loss, possibly as a consequence of preserving or enhancing lean body mass. As valuable as exercise is, the existing research literature on overweight individuals indicates that exercise programs alone do not produce significant weight loss in the populations studied.

It should be emphasized, however, that a large number of such studies have been conducted with middle-aged Caucasian women leading sedentary lifestyles.

The failure of exercise alone to produce significant weight loss may be because the neurochemical mechanisms that regulate eating behavior cause individuals to compensate for the calories expended in exercise by increasing food calorie intake.

While exercise programs can result in an average weight loss of 2 to 3 kg in the short-term Blair, ; Pavlou et al. For example, when physical activity was combined with a reduced-calorie diet and lifestyle change, a weight loss of 7.

Physical activity plus diet produces better results than either diet or physical activity alone Blair, ; Dyer, ; Pavlou et al. In addition, weight regain is significantly less likely when physical activity is combined with any other weight-reduction regimen Blair, ; Klem et al. Continued follow-up after weight loss is associated with improved outcome if the activity plan is monitored and modified as part of this follow-up Kayman et al.

While studies have shown that military recruits were able to lose significant amounts of weight during initial entry training through exercise alone, the restricted time available to consume meals during training probably contributed to this weight loss Lee et al.

The use of behavior and lifestyle modification in weight management is based on a body of evidence that people become or remain overweight as the result of modifiable habits or behaviors see Chapter 3 , and that by changing those behaviors, weight can be lost and the loss can be maintained.

The primary goals of behavioral strategies for weight control are to increase physical activity and to reduce caloric intake by altering eating habits Brownell and Kramer, ; Wilson, A subcategory of behavior modification, environmental management, is discussed in the next section.

Behavioral treatment, which was introduced in the s, may be provided to a single individual or to groups of clients. In the past, behavioral approaches were applied as stand-alone treatments to simply modify eating habits and reduce caloric intake.

However, more recently, these treatments have been used in combination with low-calorie diets, medical nutrition therapy, nutrition education, exercise programs, monitoring, pharmacological agents, and social support to promote weight loss, and as a component of maintenance programs.

Self-monitoring of dietary intake and physical activity, which enables the individual to develop a sense of accountability, is one of the cornerstones of behavioral treatment.

Patients are asked to keep a daily food diary in which they record what and how much they have eaten, when and where the food was consumed, and the context in which the food was consumed e. Additionally, patients may be asked to keep a record of their daily physical activities.

Self-monitoring of food intake is often associated with a relatively immediate reduction in food intake and consequent weight loss Blundell, ; Goris et al. The information obtained from the food diaries also is used to identify personal and environmental factors that contribute to overeating and to select and implement appropriate weight-loss strategies for the individual Wilson, The same may be true of physical activity monitoring, although little research has been conducted in this area.

Self-monitoring also provides a way for therapists and patients to evaluate which techniques are working and how changes in eating behavior or activity are contributing to weight loss. Recent work has suggested that regular self-monitoring of body weight is a useful adjunct to behavior modification programs Jeffery and French, Some additional techniques included in behavioral treatment programs include eating only regularly scheduled meals; doing nothing else while eating; consuming meals only in one place usually the dining room and leaving the table after eating; shopping only from a list; and shopping on a full stomach Brownell and Kramer, Reinforcement techniques are also an integral part of the behavioral treatment of overweight and obesity.

For example, subjects may select a positively reinforcing event, such as participating in a particularly enjoyable activity or purchasing a special item when a goal is met Brownell and Kramer, Another important component of behavioral treatment programs may be cognitive restructuring of erroneous or dysfunctional beliefs about weight regulation Wing, Techniques developed by cognitive behavior therapists can be used to help the individual identify specific triggers for overeating, deal with negative attitudes towards obesity in society, and realize that a minor dietary infraction does not mean failure.

Nutrition education and social support, discussed later in this chapter, are also components of behavioral programs. Behavioral treatments of obesity are frequently successful in the short-term.

However, the long-term effectiveness of these treatments is more controversial, with data suggesting that many individuals return to their initial body weight within 3 to 5 years after treatment has ended Brownell and Kramer, ; Klem et al. Techniques for improving the long-term benefits of behavioral treatments include: 1 developing criteria to match patients to treatments, 2 increasing initial weight loss, 3 increasing the length of treatment, 4 emphasizing the role of exercise, and 5 combining behavioral programs with other treatments such as pharmacotherapy, surgery, or stringent diets Brownell and Kramer, Recent studies of individuals who have achieved success at long-term weight loss may offer other insights into ways to improve behavioral treatment strategies.

In their analysis of data from the National Weight Control Registry, Klem and coworkers found that weight loss achieved through exercise, sensible dieting, reduced fat consumption, and individual behavior changes could be maintained for long periods of time.

However, this population was self-selected so it does not represent the experience of the average person in a civilian population. Because they have achieved and maintained a significant amount of weight loss at least 30 lb for 2 or more years , there is reason to believe that the population enrolled in the Registry may be especially disciplined.

As such, the experience of people in the Registry may provide insight into the military population, although evidence to assert this with authority is lacking. In any case, the majority of participants in the Registry report they have made significant permanent changes in their behavior, including portion control, low-fat food selection, 60 or more minutes of daily exercise, self-monitoring, and well-honed problem-solving skills.

A significant part of weight loss and management may involve restructuring the environment that promotes overeating and underactivity.

The environment includes the home, the workplace, and the community e. Environmental factors include the availability of foods such as fruits, vegetables, nonfat dairy products, and other foods of low energy density and high nutritional value.

Environmental restructuring empha-sizes frequenting dining facilities that produce appealing foods of lower energy density and providing ample time for eating a wholesome meal rather than grabbing a candy bar or bag of chips and a soda from a vending machine.

Busy lifestyles and hectic work schedules create eating habits that may contribute to a less than desirable eating environment, but simple changes can help to counter-act these habits. Commanders of military bases should examine their facilities to identify and eliminate conditions that encourage one or more of the eating habits that promote overweight.

Some nonmilitary employers have increased healthy eating options at worksite dining facilities and vending machines. Although multiple publications suggest that worksite weight-loss programs are not very effective in reducing body weight Cohen et al.

Opting for high-fat snack foods from strategically placed vending machines or snack shops combined with allowing insufficient time to prepare affordable, healthier alternatives.

Major obstacles to exercise, even in highly motivated people, include the time it takes to complete the task and the inaccessibility of facilities or safe places to exercise. Environmental interventions emphasize the many ways that physical activity can be fit into a busy lifestyle and seek to make use of whatever opportunities are available HHS, The availability of safe sidewalks and parks and alternative methods of transportation to work, such as walking or bicycling, also enhance the physical activity environment.

Management of overweight and obesity requires the active participation of the individual. Nutrition professionals can provide individuals with a base of information that allows them to make knowledgeable food choices.

Nutrition education is distinct from nutrition counseling, although the contents overlap considerably. Nutrition counseling and dietary management tend to focus more directly on the motivational, emotional, and psychological issues associated with the current task of weight loss and weight management.

It addresses the how of behavioral changes in the dietary arena. Nutrition education on the other hand, provides basic information about the scientific foundation of nutrition that enables people to make informed decisions about food, cooking methods, eating out, and estimating portion sizes.

Nutrition education programs also may provide information on the role of nutrition in health promotion and disease prevention, sports nutrition, and nutrition for pregnant and lactating women. Effective nutrition education imparts nutrition knowledge and its use in healthy living.

For example, it explains the concept of energy balance in weight management in an accessible, practical way that has meaning to the individual's lifestyle, including that in the military setting. Written materials prepared by various government agencies or by nonprofit health organizations can be used effectively to provide nutrition education.

However, written materials are most effective when used to reinforce informal classroom or counseling sessions and to provide specific information, such as a table of the calorie content of foods.

The format of education programs varies considerably, and can include formal classes, informal group meetings, or teleconferencing. A common background among group members is helpful but seldom possible. Educational formats that provide practical and relevant nutrition information for program participants are the most successful.

For example, some military weight-management programs include field trips to post exchanges, restaurants fast-food and others , movies, and other places where food is purchased or consumed Vorachek, The involvement of spouses and other family members in an education program increases the likelihood that other members of the household will make permanent changes, which in turn enhances the likelihood that the program participants will continue to lose weight or maintain weight loss Hart et al.

Particular attention must be directed to involvement of those in the household who are most likely to shop for and prepare food. Unless the program participant lives alone, nutrition management is rarely effective without the involvement of family members.

Weight-management programs may be divided into two phases: weight loss and weight maintenance. While exercise may be the most important element of a weight-maintenance program, it is clear that dietary restriction is the critical component of a weight-loss program that influences the rate of weight loss.

Activity accounts for only about 15 to 30 percent of daily energy expenditure, but food intake accounts for percent of energy intake. Thus, the energy balance equation may be affected most significantly by reducing energy intake. The number of diets that have been proposed is almost innumerable, but whatever the name, all diets consist of reductions of some proportions of protein, carbohydrate CHO and fat.

The following sections examine a number of arrangements of the proportions of these three energy-containing macronutrients. A nutritionally balanced, hypocaloric diet has been the recommendation of most dietitians who are counseling patients who wish to lose weight.

This type of diet is composed of the types of foods a patient usually eats, but in lower quantities. There are a number of reasons such diets are appealing, but the main reason is that the recommendation is simple—individuals need only to follow the U.

Department of Agriculture's Food Guide Pyramid. The Pyramid recommends that individuals eat a variety of foods, with the majority being grain products e. In using the Pyramid, however, it is important to emphasize the portion sizes used to establish the recommended number of servings.

For example, a majority of consumers do not realize that a portion of bread is a single slice or that a portion of meat is only 3 oz. A diet based on the Pyramid is easily adapted from the foods served in group settings, including military bases, since all that is required is to eat smaller portions.

Even with smaller portions, it is not difficult to obtain adequate quantities of the other essential nutrients.

Many of the studies published in the medical literature are based on a balanced hypocaloric diet with a reduction of energy intake by to 1, kcal from the patient's usual caloric intake. The U. Meal replacement programs are commercially available to consumers for a reasonably low cost.

The meal replacement industry suggests replacing one or two of the three daily meals with their products, while the third meal should be sensibly balanced. In addition, two snacks consisting of fruits, vegetables, or diet snack bars are recommended each day.

A number of studies have evaluated long-term weight maintenance using meal replacement, either self-managed Flechtner-Mors et al. The largest amount of weight loss occurred early in the studies about the first 3 months of the plan Ditschuneit et al.

One study found that women lost more weight between the third and sixth months of the plan, but men lost most of their weight by the third month Heber et al.

All of the studies resulted in maintenance of significant weight loss after 2 to 5 years of follow-up. Hill's review of Rothacker pointed out that the group receiving meal replacements maintained a small, yet significant, weight loss over the 5-year program, whereas the control group gained a significant amount of weight.

Active intervention, which included dietary counseling and behavior modification, was more effective in weight maintenance when meal replacements were part of the diet Ashley et al. Meal replacements were also found to improve food patterns, including nutrient distribution, intake of micronutrients, and maintenance of fruit and vegetable intake.

Long-term maintenance of weight loss with meal replacements improves biomarkers of disease risk, including improvements in levels of blood glucose Ditschuneit and Fletchner-Mors, , insulin, and triacylglycerol; improved systolic blood pressure Ditschuneit and Fletchner-Mors, ; Ditschuneit et al.

Winick and coworkers evaluated employees in high-stress jobs e. The meal replacements were found to be effective in reducing weight and maintaining weight loss at a 1-year follow-up. In contrast, Bendixen and coworkers reported from Denmark that meal replacements were associated with negative outcomes on weight loss and weight maintenance.

However, this was not an intervention study; participants were followed for 6 years by phone interview and data were self-reported. Unbalanced, hypocaloric diets restrict one or more of the calorie-containing macronutrients protein, fat, and CHO.

The rationale given for these diets by their advocates is that the restriction of one particular macronutrient facilitates weight loss, while restriction of the others does not. Many of these diets are published in books aimed at the lay public and are often not written by health professionals and often are not based on sound scientific nutrition principles.

For some of the dietary regimens of this type, there are few or no research publications and virtually none have been studied long term. Therefore, few conclusions can be drawn about the safety, and even about the efficacy, of such diets.

The major types of unbalanced, hypocaloric diets are discussed below. There has been considerable debate on the optimal ratio of macronutrient intake for adults. This research usually compares the amount of fat and CHO; however, there has been increasing interest in the role of protein in the diet Hu et al.

Although the high-protein diet does not produce significantly different weight loss compared with the high-CHO diet Layman et al. High-protein, low-CHO diets were introduced to the American public during the s and s by Stillman and Baker and by Atkins Atkins, ; Atkins and Linde, , and more recently, by Sears and Lawren While most of these diets have been promoted by nonscientists who have done little or no serious scientific research, some of the regimens have been subjected to rigorous studies Skov et al.

There remains, however, a lack of randomized clinical trials of 2 or more years' duration, which are needed to evaluate the potent beneficial effect of weight loss accomplished using virtually any dietary regimen, no matter how unbalanced on blood lipids.

In addition, longer studies are needed to separate the beneficial effects of weight loss from the long-term effects of consuming an unbalanced diet. These claims are unsupported by scientific data. Although these diets are prescribed to be eaten ad libitum, total daily energy intake tends to be reduced as a result of the monotony of the food choices, other prescripts of the diet, and an increased satiety effect of protein.

In addition, the restriction of CHO intake leads to the loss of glycogen and marked diuresis Coulston and Rock, ; Miller and Lindeman, ; Pi-Sunyer, Thus, the relatively rapid initial weight loss that occurs on these diets predominantly reflects the loss of body water rather than stored fat.

This can be a significant concern for military personnel, where even mild dehydration can have detrimental effects on physical and cognitive performance. For example, small changes in hydration status can affect a military pilot's ability to sense changes in equilibrium.

Results of several recent studies suggest that high-protein, low-CHO diets may have their benefits. In addition to sparing fat-free mass Piatti et al. Furthermore, a percent protein diet reduced resting energy expenditure to a significantly lesser extent than did a percent protein diet Baba et al.

The length of these studies that examined high-protein diets only lasted 1 year or less; the long-term safety of these diets is not known. Low-fat diets have been one of the most commonly used treatments for obesity for many years Astrup, ; Astrup et al. The most extreme forms of these diets, such as those proposed by Ornish and Pritikin , recommend fat intakes of no more than 10 percent of total caloric intake.

Although these stringent diets can lead to weight loss, the limited array of food choices make them difficult to maintain for extended periods of time by individuals who wish to follow a normal lifestyle. More modest reductions in fat intake, which make a dietary regimen easier to follow and more acceptable to many individuals, can also promote weight loss Astrup, ; Astrup et al.

For example, Sheppard and colleagues reported that after 1 year, obese women who reduced their fat intake from approximately 39 percent to 22 percent of total caloric intake lost 3. Results of recent studies suggest that fat restriction is also valuable for weight maintenance in those who have lost weight Flatt ; Miller and Lindeman, Dietary fat reduction can be achieved by counting and limiting the number of grams or calories consumed as fat, by limiting the intake of certain foods for example, fattier cuts of meat , and by substituting reduced-fat or nonfat versions of foods for their higher fat counterparts e.

Over the past decade, pursuit of this latter strategy has been simplified by the burgeoning availability of low-fat or fat-free products, which have been marketed in response to evidence that decreasing fat intake can aid in weight control.

The mechanisms for weight loss on a low-fat diet are not clear. Weight loss may be solely the result of a reduction in total energy intake, but another possibility is that a low-fat diet may alter metabolism Astrup, ; Astrup et al.

Support for the latter possibility has come from studies showing that the short-term adherence to a diet containing 20 or 30 percent of calories from fat increased hour energy expenditure in formerly obese women, relative to an isocaloric diet with 40 percent of calories from fat Astrup et al.

Over the past two decades, fat consumption as a percent of total caloric intake has declined in the United States Anand and Basiotis, , while average body weight and the proportion of the American population suffering from obesity have increased significantly Mokdad et al.

Several factors may contribute to this seeming contradiction. First, all individuals appear to selectively underestimate their intake of dietary fat and to decrease normal fat intake when asked to record it Goris et al. If these results reflect the general tendencies of individuals completing dietary surveys, then the amount of fat being consumed by obese and, possibly, nonobese people, is greater than routinely reported.

Second, although the proportion of total calories consumed as fat has decreased over the past 20 years, grams of fat intake per day have remained steady or increased Anand and Basiotis, , indicating that total energy intake increased at a faster rate than did fat intake. Coupled with these findings is the fact that since the early s, the availability of low-fat and nonfat, but calorie-rich snack foods e.

However, total energy intake still matters, and overconsumption of these low-fat snacks could as easily lead to weight gain as intake of their high-fat counterparts Allred, Two recent, comprehensive reviews have reported on the overall impact of low-fat diets.

Astrup and coworkers examined four meta-analyses of weight change that occurred on intervention trials with ad libitum low-fat diets. They found that low-fat diets consistently demonstrated significant weight loss, both in normal-weight and overweight individuals. A dose-response relationship was also observed in that a 10 percent reduction in dietary fat was predicted to produce a 4- to 5-kg weight loss in an individual with a BMI of Most low-fat diets are also high in dietary fiber, and some investigators attribute the beneficial effects of low-fat diets to the high content of vegetables and fruits that contain large amounts of dietary fiber.

The rationale for using high-fiber diets is that they may reduce energy intake and may alter metabolism Raben et al. The beneficial effects of dietary fiber might be accomplished by the following mechanisms: 1 caloric dilution most high-fiber foods are low in calories and low in fat ; 2 longer chewing and swallowing time reduces total intake; 3 improved gastric and intestinal motility and emptying and less absorption French and Read, ; Leeds, ; McIntyre et al.

Dietary fiber is not a panacea, and the vast majority of controlled studies of the effects of dietary fiber on weight loss show minimal or no reduction in body weight LSRO, ; Pasman et al. Many individuals and companies promote the use of dietary fiber supplements for weight loss and reductions in cardiovascular and cancer risks.

Numerous studies, usually short-term and using purified or partially purified dietary fiber, have shown reductions in serum lipids, glucose, or insulin Jenkins et al. Long-term studies have usually not confirmed these findings LSRO, ; Pasman et al.

Current recommendations suggest that instead of eating dietary fiber supplements, a diet of foods high in whole fruits and vegetables may have favorable effects on cardiovascular and cancer risk factors Bruce et al.

Such diets are often lower in fat and higher in CHOs. Very-low-calorie diets VLCDs were used extensively for weight loss in the s and s, but have fallen into disfavor in recent years Atkinson, ; Bray, a; Fisler and Drenick, The VLCDs used most frequently consist of powdered formulas or limited-calorie servings of foods that contain a high-quality protein source, CHO, a small percentage of calories as fat, and the daily recommendations of vitamins and minerals Kanders and Blackburn, ; Wadden, The servings are eaten three to five times per day.

The primary goal of VLCDs is to produce relatively rapid weight loss without substantial loss in lean body mass. To achieve this goal, VLCDs usually provide 1. VLCDs are not appropriate for all overweight individuals, and they are usually limited to patients with a BMI of greater than 25 some guidelines suggest a BMI of 27 or even 30 who have medical complications associated with being overweight and have already tried more conservative treatment programs.

Additionally, because of the potential detrimental side effects of these diets e. On a short-term basis, VLCDs are relatively effective, with weight losses of approximately 15 to 30 kg over 12 to 20 weeks being reported in a number of studies Anderson et al.

However, the long-term effectiveness of these diets is somewhat limited. Approximately 40 to 50 percent of patients drop out of the program before achieving their weight-loss goals. In addition, relatively few people who lose large amounts of weight using VLCDs are able to sustain the weight loss when they resume normal eating.

In two studies, only 30 percent of patients who reached their goal were able to maintain their weight loss for at least 18 months. Within 1 year, the majority of patients regained approximately two-thirds of the lost weight Apfelbaum et al.

In a more recent study with longer followup, the average regain over the first 3 years of follow-up was 73 percent. However, weight tended to stabilize over the fourth year. At 5 years, the dieters had maintained an average of 23 percent of their initial weight loss. At 7 years, 25 percent of the dieters were maintaining a weight loss of 10 percent of their initial body weight Anderson et al.

It appears that VLCDs are more effective for long-term weight loss than hypocaloric-balanced diets. In a meta-analysis of 29 studies, Anderson and colleagues examined the long-term weight-loss maintenance of individuals put on a VLCD diet with behavioral modification as compared with individuals put on a hypocaloric-balanced diet.

They found that VLCD participants lost significantly more weight initially and maintained significantly more weight loss than participants on the hypocaloric-balanced diet see Table Almost any kind of assistance provided to participants in a weight-management program can be characterized as support services.

These can include emotional support, dietary support, and support services for physical activity. The support services used most often are structured in a standard way.

Other services are developed to meet the specific needs of a site, program, or the individual involved. With few exceptions, almost any weight-management program is likely to be more successful if it is accompanied by support services Heshka et al. However, not all services will be productively applicable to all patients, and not all can be made available in all settings.

Furthermore, some weight-loss program participants will be reluctant to use any support services. Psychological and emotional factors play a significant role in weight management.

Counseling services are those that consider psychological issues associated with inappropriate eating and that are structured to inform the patient about the nature of these issues, their implications, and the possibilities available for their ongoing management.

This intervention is less elaborate, intense, and sustaining than psychotherapy services. For example, it should be useful to help patients understand the existence and nature of a sabotaging household or the phenomenon of stress-related eating without undertaking continuing psychotherapy.

A counselor or therapist can provide this service either in individual or group sessions. These counselors should, however, be sufficiently familiar with the issues that arise with weight-management programs, such as binge eating and purging.

Short-term, individual case management can be helpful, as can group sessions because patients can hear the perspective of other individuals with similar weight-management concerns while addressing their individual concerns Hughes et al.

Psychotherapy services, both individual and group, can also be useful. However, the costs of this type of service limits its applicability to many patients.

Nevertheless, the value for individual patients can be substantial, and the option should not be dismissed simply because of cost. Concerns about childhood abuse, emotional linkages to sustaining obesity fat-dependent personality , and the management of coexisting mental health problems are the kinds of issues that might be addressed with this type of support service.

The individual therapist can structure the format of the therapy but, as with counseling services, the therapist should be familiar with weight-management issues. Nonprofessional patient-led groups and counseling, such as those available with organized programs like Take Off Pounds Sensibly and Overeaters Anonymous, can be useful adjuncts to weight-loss efforts.

These programs have the advantages of low cost, continuing support and encouragement, and a semi-structured approach to the issues that arise among weight-management patients. Their disadvantage is that, since the counseling is nonprofessional in nature, the programs are only as good as the people who are involved.

These peer-support programs are more likely to be productive when they are used as a supplement to a program with professional therapists and counselors. In Overeaters Anonymous, a variant of these groups is a sponsor-system program that pairs individuals who can help one another.

Certain commercial programs like Weight Watchers and Jenny Craig can also be helpful. Since commercial groups have their own agenda, caution must be exercised to avoid contradictions between the advice of professional counselors and that of the supportive commercial program.

Since the counselors in commercial programs are not likely to be professionals, the quality of counseling offered by these programs varies with the training of the counselors.

Many communities offer supplemental weight-management services. Educational services, particularly in nutrition, may be provided through community adult education using teaching materials from nonprofit organizations such as the American Heart Association, the American Diabetes Association, and government agencies FDA, National Institutes of Health, and U.

Department of Agriculture. Many community hospitals have staff dietitians who are available for out-patient individual counseling Pavlou et al. However, the military's TRICARE health services contracts would need to be modified to include dietitian services from community hospitals or other community services since these contracts do not currently include medical nutrition therapy and therefore dietitian counseling.

The family unit can be a source of significant assistance to an individual in a weight-management program. For example, program dropout rates tend to be lower when a participant's spouse is involved in the program Jeffery et al.

With simple guidance and direction, the involvement of the spouse as a form of reinforcement rather than as a source of discipline and monitoring can become a resource to assist in supporting the participant. However, individual family members or the family as a group can become an obstacle when they express reluctance to make changes in food and eating patterns within the household.

Issues of family conflict become more complex when the participants are children or adolescents or when spouses are reluctant to relinquish status quo positions of control.

A variety of Internet- and web-related services are available to individuals who are trying to manage their weight Davison, ; Gray and Raab, ; Riva et al. As with any other Internet service, the quality of these sites varies substantially Miles et al.

An important role for weight-management professionals is to review such sites so they can recommend those that are the most useful. The use of e-mail counseling services by military personnel who travel frequently or who are stationed in remote locations has been tested at one facility; initial results are promising James et al.

The use of web-based modalities by qualified counselors or facilitators located at large military installations would extend the accessibility of such services to personnel located at small bases or stationed in remote locations.

Support is also required for military personnel who need to enhance their levels of physical fitness and physical activity. All branches of the services have remedial physical fitness training programs for personnel who fail their fitness test, but support is also needed for those who need to lose weight and for all personnel to aid in maintaining proper weight.

Support services should include personnel, facilities, and equipment, and should provide practical advice on how to begin and progress through physical training routines including proper use of training equipment and how to prevent musculoskeletal injuries , as well as advice on when and how to eat in conjunction with physical activity demands.

Success in the promotion of weight loss can sometimes be achieved with the use of drugs. It has been shown that one of the benefits, an increase in high-density lipoproteins, can be achieved with a threshold level of aerobic exercise of 10 to 11 hours per month.

For previously sedentary individuals, a slow progression in physical activity has been recommended so that 30 minutes of exercise daily is achieved after several weeks of gradual build-up.

This may also apply to some military personnel, especially new recruits or reservists recalled to active duty who may be entering service from previously very sedentary lifestyles. For that purpose, a weekly goal of 2, to 3, kcal of added activity may be necessary Klem et al. Thus, mental preparation for the amount of activity necessary to maintain weight loss must begin while losing weight Brownell, For many individuals, changing activity levels is perceived as more unpleasant than changing dietary habits.

However, over an month period, individuals who performed short bouts of physical activity did not experience improvements in long-term weight loss, cardiorespiratory fitness, or physical activity participation in comparison with those who performed longer bouts of exercise.

Some evidence suggests that home exercise equipment e. In addition, individual preferences are paramount considerations in choices of activity. When strength training or resistance exercise is combined with aerobic activity, long-term results may be better than those with aerobics alone Poirier and Despres, ; Sothern et al.

Because strength training tends to build muscle, loss of lean body mass may be minimized and the relative loss of body fat may be increased. An added benefit is the attenuation of the decrease in resting metabolic rate associated with weight loss, possibly as a consequence of preserving or enhancing lean body mass.

As valuable as exercise is, the existing research literature on overweight individuals indicates that exercise programs alone do not produce significant weight loss in the populations studied.

It should be emphasized, however, that a large number of such studies have been conducted with middle-aged Caucasian women leading sedentary lifestyles. The failure of exercise alone to produce significant weight loss may be because the neurochemical mechanisms that regulate eating behavior cause individuals to compensate for the calories expended in exercise by increasing food calorie intake.

While exercise programs can result in an average weight loss of 2 to 3 kg in the short-term Blair, ; Pavlou et al.

For example, when physical activity was combined with a reduced-calorie diet and lifestyle change, a weight loss of 7. Physical activity plus diet produces better results than either diet or physical activity alone Blair, ; Dyer, ; Pavlou et al.

In addition, weight regain is significantly less likely when physical activity is combined with any other weight-reduction regimen Blair, ; Klem et al. Continued follow-up after weight loss is associated with improved outcome if the activity plan is monitored and modified as part of this follow-up Kayman et al.

While studies have shown that military recruits were able to lose significant amounts of weight during initial entry training through exercise alone, the restricted time available to consume meals during training probably contributed to this weight loss Lee et al.

The use of behavior and lifestyle modification in weight management is based on a body of evidence that people become or remain overweight as the result of modifiable habits or behaviors see Chapter 3 , and that by changing those behaviors, weight can be lost and the loss can be maintained.

The primary goals of behavioral strategies for weight control are to increase physical activity and to reduce caloric intake by altering eating habits Brownell and Kramer, ; Wilson, A subcategory of behavior modification, environmental management, is discussed in the next section.

Behavioral treatment, which was introduced in the s, may be provided to a single individual or to groups of clients. In the past, behavioral approaches were applied as stand-alone treatments to simply modify eating habits and reduce caloric intake.

However, more recently, these treatments have been used in combination with low-calorie diets, medical nutrition therapy, nutrition education, exercise programs, monitoring, pharmacological agents, and social support to promote weight loss, and as a component of maintenance programs.

Self-monitoring of dietary intake and physical activity, which enables the individual to develop a sense of accountability, is one of the cornerstones of behavioral treatment. Patients are asked to keep a daily food diary in which they record what and how much they have eaten, when and where the food was consumed, and the context in which the food was consumed e.

Additionally, patients may be asked to keep a record of their daily physical activities. Self-monitoring of food intake is often associated with a relatively immediate reduction in food intake and consequent weight loss Blundell, ; Goris et al.

The information obtained from the food diaries also is used to identify personal and environmental factors that contribute to overeating and to select and implement appropriate weight-loss strategies for the individual Wilson, The same may be true of physical activity monitoring, although little research has been conducted in this area.

Self-monitoring also provides a way for therapists and patients to evaluate which techniques are working and how changes in eating behavior or activity are contributing to weight loss. Recent work has suggested that regular self-monitoring of body weight is a useful adjunct to behavior modification programs Jeffery and French, Some additional techniques included in behavioral treatment programs include eating only regularly scheduled meals; doing nothing else while eating; consuming meals only in one place usually the dining room and leaving the table after eating; shopping only from a list; and shopping on a full stomach Brownell and Kramer, Reinforcement techniques are also an integral part of the behavioral treatment of overweight and obesity.

For example, subjects may select a positively reinforcing event, such as participating in a particularly enjoyable activity or purchasing a special item when a goal is met Brownell and Kramer, Another important component of behavioral treatment programs may be cognitive restructuring of erroneous or dysfunctional beliefs about weight regulation Wing, Techniques developed by cognitive behavior therapists can be used to help the individual identify specific triggers for overeating, deal with negative attitudes towards obesity in society, and realize that a minor dietary infraction does not mean failure.

Nutrition education and social support, discussed later in this chapter, are also components of behavioral programs. Behavioral treatments of obesity are frequently successful in the short-term. However, the long-term effectiveness of these treatments is more controversial, with data suggesting that many individuals return to their initial body weight within 3 to 5 years after treatment has ended Brownell and Kramer, ; Klem et al.

Techniques for improving the long-term benefits of behavioral treatments include: 1 developing criteria to match patients to treatments, 2 increasing initial weight loss, 3 increasing the length of treatment, 4 emphasizing the role of exercise, and 5 combining behavioral programs with other treatments such as pharmacotherapy, surgery, or stringent diets Brownell and Kramer, Recent studies of individuals who have achieved success at long-term weight loss may offer other insights into ways to improve behavioral treatment strategies.

In their analysis of data from the National Weight Control Registry, Klem and coworkers found that weight loss achieved through exercise, sensible dieting, reduced fat consumption, and individual behavior changes could be maintained for long periods of time.

However, this population was self-selected so it does not represent the experience of the average person in a civilian population. Because they have achieved and maintained a significant amount of weight loss at least 30 lb for 2 or more years , there is reason to believe that the population enrolled in the Registry may be especially disciplined.

As such, the experience of people in the Registry may provide insight into the military population, although evidence to assert this with authority is lacking. In any case, the majority of participants in the Registry report they have made significant permanent changes in their behavior, including portion control, low-fat food selection, 60 or more minutes of daily exercise, self-monitoring, and well-honed problem-solving skills.

A significant part of weight loss and management may involve restructuring the environment that promotes overeating and underactivity. The environment includes the home, the workplace, and the community e.

Environmental factors include the availability of foods such as fruits, vegetables, nonfat dairy products, and other foods of low energy density and high nutritional value. Environmental restructuring empha-sizes frequenting dining facilities that produce appealing foods of lower energy density and providing ample time for eating a wholesome meal rather than grabbing a candy bar or bag of chips and a soda from a vending machine.

Busy lifestyles and hectic work schedules create eating habits that may contribute to a less than desirable eating environment, but simple changes can help to counter-act these habits. Commanders of military bases should examine their facilities to identify and eliminate conditions that encourage one or more of the eating habits that promote overweight.

Some nonmilitary employers have increased healthy eating options at worksite dining facilities and vending machines. Although multiple publications suggest that worksite weight-loss programs are not very effective in reducing body weight Cohen et al.

Opting for high-fat snack foods from strategically placed vending machines or snack shops combined with allowing insufficient time to prepare affordable, healthier alternatives.

Major obstacles to exercise, even in highly motivated people, include the time it takes to complete the task and the inaccessibility of facilities or safe places to exercise. Environmental interventions emphasize the many ways that physical activity can be fit into a busy lifestyle and seek to make use of whatever opportunities are available HHS, The availability of safe sidewalks and parks and alternative methods of transportation to work, such as walking or bicycling, also enhance the physical activity environment.

Management of overweight and obesity requires the active participation of the individual. Nutrition professionals can provide individuals with a base of information that allows them to make knowledgeable food choices. Nutrition education is distinct from nutrition counseling, although the contents overlap considerably.

Nutrition counseling and dietary management tend to focus more directly on the motivational, emotional, and psychological issues associated with the current task of weight loss and weight management. It addresses the how of behavioral changes in the dietary arena. Nutrition education on the other hand, provides basic information about the scientific foundation of nutrition that enables people to make informed decisions about food, cooking methods, eating out, and estimating portion sizes.

Nutrition education programs also may provide information on the role of nutrition in health promotion and disease prevention, sports nutrition, and nutrition for pregnant and lactating women. Effective nutrition education imparts nutrition knowledge and its use in healthy living.

For example, it explains the concept of energy balance in weight management in an accessible, practical way that has meaning to the individual's lifestyle, including that in the military setting.

Written materials prepared by various government agencies or by nonprofit health organizations can be used effectively to provide nutrition education.

However, written materials are most effective when used to reinforce informal classroom or counseling sessions and to provide specific information, such as a table of the calorie content of foods.

The format of education programs varies considerably, and can include formal classes, informal group meetings, or teleconferencing. A common background among group members is helpful but seldom possible.

Educational formats that provide practical and relevant nutrition information for program participants are the most successful. For example, some military weight-management programs include field trips to post exchanges, restaurants fast-food and others , movies, and other places where food is purchased or consumed Vorachek, The involvement of spouses and other family members in an education program increases the likelihood that other members of the household will make permanent changes, which in turn enhances the likelihood that the program participants will continue to lose weight or maintain weight loss Hart et al.

Particular attention must be directed to involvement of those in the household who are most likely to shop for and prepare food. Unless the program participant lives alone, nutrition management is rarely effective without the involvement of family members.

Weight-management programs may be divided into two phases: weight loss and weight maintenance. While exercise may be the most important element of a weight-maintenance program, it is clear that dietary restriction is the critical component of a weight-loss program that influences the rate of weight loss.

Activity accounts for only about 15 to 30 percent of daily energy expenditure, but food intake accounts for percent of energy intake. Thus, the energy balance equation may be affected most significantly by reducing energy intake. The number of diets that have been proposed is almost innumerable, but whatever the name, all diets consist of reductions of some proportions of protein, carbohydrate CHO and fat.

The following sections examine a number of arrangements of the proportions of these three energy-containing macronutrients. A nutritionally balanced, hypocaloric diet has been the recommendation of most dietitians who are counseling patients who wish to lose weight.

This type of diet is composed of the types of foods a patient usually eats, but in lower quantities. There are a number of reasons such diets are appealing, but the main reason is that the recommendation is simple—individuals need only to follow the U.

Department of Agriculture's Food Guide Pyramid. The Pyramid recommends that individuals eat a variety of foods, with the majority being grain products e.

In using the Pyramid, however, it is important to emphasize the portion sizes used to establish the recommended number of servings. For example, a majority of consumers do not realize that a portion of bread is a single slice or that a portion of meat is only 3 oz. A diet based on the Pyramid is easily adapted from the foods served in group settings, including military bases, since all that is required is to eat smaller portions.

Even with smaller portions, it is not difficult to obtain adequate quantities of the other essential nutrients. Many of the studies published in the medical literature are based on a balanced hypocaloric diet with a reduction of energy intake by to 1, kcal from the patient's usual caloric intake.

The U. Meal replacement programs are commercially available to consumers for a reasonably low cost. The meal replacement industry suggests replacing one or two of the three daily meals with their products, while the third meal should be sensibly balanced.

In addition, two snacks consisting of fruits, vegetables, or diet snack bars are recommended each day. A number of studies have evaluated long-term weight maintenance using meal replacement, either self-managed Flechtner-Mors et al.

The largest amount of weight loss occurred early in the studies about the first 3 months of the plan Ditschuneit et al. One study found that women lost more weight between the third and sixth months of the plan, but men lost most of their weight by the third month Heber et al.

All of the studies resulted in maintenance of significant weight loss after 2 to 5 years of follow-up. Hill's review of Rothacker pointed out that the group receiving meal replacements maintained a small, yet significant, weight loss over the 5-year program, whereas the control group gained a significant amount of weight.

Active intervention, which included dietary counseling and behavior modification, was more effective in weight maintenance when meal replacements were part of the diet Ashley et al. Meal replacements were also found to improve food patterns, including nutrient distribution, intake of micronutrients, and maintenance of fruit and vegetable intake.

Long-term maintenance of weight loss with meal replacements improves biomarkers of disease risk, including improvements in levels of blood glucose Ditschuneit and Fletchner-Mors, , insulin, and triacylglycerol; improved systolic blood pressure Ditschuneit and Fletchner-Mors, ; Ditschuneit et al.

Winick and coworkers evaluated employees in high-stress jobs e. The meal replacements were found to be effective in reducing weight and maintaining weight loss at a 1-year follow-up.

In contrast, Bendixen and coworkers reported from Denmark that meal replacements were associated with negative outcomes on weight loss and weight maintenance.

However, this was not an intervention study; participants were followed for 6 years by phone interview and data were self-reported. Unbalanced, hypocaloric diets restrict one or more of the calorie-containing macronutrients protein, fat, and CHO.

The rationale given for these diets by their advocates is that the restriction of one particular macronutrient facilitates weight loss, while restriction of the others does not. Many of these diets are published in books aimed at the lay public and are often not written by health professionals and often are not based on sound scientific nutrition principles.

For some of the dietary regimens of this type, there are few or no research publications and virtually none have been studied long term.

Therefore, few conclusions can be drawn about the safety, and even about the efficacy, of such diets. The major types of unbalanced, hypocaloric diets are discussed below. There has been considerable debate on the optimal ratio of macronutrient intake for adults.

This research usually compares the amount of fat and CHO; however, there has been increasing interest in the role of protein in the diet Hu et al. Although the high-protein diet does not produce significantly different weight loss compared with the high-CHO diet Layman et al.

High-protein, low-CHO diets were introduced to the American public during the s and s by Stillman and Baker and by Atkins Atkins, ; Atkins and Linde, , and more recently, by Sears and Lawren While most of these diets have been promoted by nonscientists who have done little or no serious scientific research, some of the regimens have been subjected to rigorous studies Skov et al.

There remains, however, a lack of randomized clinical trials of 2 or more years' duration, which are needed to evaluate the potent beneficial effect of weight loss accomplished using virtually any dietary regimen, no matter how unbalanced on blood lipids. In addition, longer studies are needed to separate the beneficial effects of weight loss from the long-term effects of consuming an unbalanced diet.

These claims are unsupported by scientific data. Although these diets are prescribed to be eaten ad libitum, total daily energy intake tends to be reduced as a result of the monotony of the food choices, other prescripts of the diet, and an increased satiety effect of protein.

In addition, the restriction of CHO intake leads to the loss of glycogen and marked diuresis Coulston and Rock, ; Miller and Lindeman, ; Pi-Sunyer, Thus, the relatively rapid initial weight loss that occurs on these diets predominantly reflects the loss of body water rather than stored fat.

This can be a significant concern for military personnel, where even mild dehydration can have detrimental effects on physical and cognitive performance. For example, small changes in hydration status can affect a military pilot's ability to sense changes in equilibrium.

Results of several recent studies suggest that high-protein, low-CHO diets may have their benefits. In addition to sparing fat-free mass Piatti et al. Furthermore, a percent protein diet reduced resting energy expenditure to a significantly lesser extent than did a percent protein diet Baba et al.

The length of these studies that examined high-protein diets only lasted 1 year or less; the long-term safety of these diets is not known. Low-fat diets have been one of the most commonly used treatments for obesity for many years Astrup, ; Astrup et al.

The most extreme forms of these diets, such as those proposed by Ornish and Pritikin , recommend fat intakes of no more than 10 percent of total caloric intake. Although these stringent diets can lead to weight loss, the limited array of food choices make them difficult to maintain for extended periods of time by individuals who wish to follow a normal lifestyle.

More modest reductions in fat intake, which make a dietary regimen easier to follow and more acceptable to many individuals, can also promote weight loss Astrup, ; Astrup et al.

For example, Sheppard and colleagues reported that after 1 year, obese women who reduced their fat intake from approximately 39 percent to 22 percent of total caloric intake lost 3.

Results of recent studies suggest that fat restriction is also valuable for weight maintenance in those who have lost weight Flatt ; Miller and Lindeman, Dietary fat reduction can be achieved by counting and limiting the number of grams or calories consumed as fat, by limiting the intake of certain foods for example, fattier cuts of meat , and by substituting reduced-fat or nonfat versions of foods for their higher fat counterparts e.

Over the past decade, pursuit of this latter strategy has been simplified by the burgeoning availability of low-fat or fat-free products, which have been marketed in response to evidence that decreasing fat intake can aid in weight control.

The mechanisms for weight loss on a low-fat diet are not clear. Weight loss may be solely the result of a reduction in total energy intake, but another possibility is that a low-fat diet may alter metabolism Astrup, ; Astrup et al.

Support for the latter possibility has come from studies showing that the short-term adherence to a diet containing 20 or 30 percent of calories from fat increased hour energy expenditure in formerly obese women, relative to an isocaloric diet with 40 percent of calories from fat Astrup et al.

Over the past two decades, fat consumption as a percent of total caloric intake has declined in the United States Anand and Basiotis, , while average body weight and the proportion of the American population suffering from obesity have increased significantly Mokdad et al. Several factors may contribute to this seeming contradiction.

First, all individuals appear to selectively underestimate their intake of dietary fat and to decrease normal fat intake when asked to record it Goris et al. If these results reflect the general tendencies of individuals completing dietary surveys, then the amount of fat being consumed by obese and, possibly, nonobese people, is greater than routinely reported.

Second, although the proportion of total calories consumed as fat has decreased over the past 20 years, grams of fat intake per day have remained steady or increased Anand and Basiotis, , indicating that total energy intake increased at a faster rate than did fat intake. Coupled with these findings is the fact that since the early s, the availability of low-fat and nonfat, but calorie-rich snack foods e.

However, total energy intake still matters, and overconsumption of these low-fat snacks could as easily lead to weight gain as intake of their high-fat counterparts Allred, Two recent, comprehensive reviews have reported on the overall impact of low-fat diets. Astrup and coworkers examined four meta-analyses of weight change that occurred on intervention trials with ad libitum low-fat diets.

They found that low-fat diets consistently demonstrated significant weight loss, both in normal-weight and overweight individuals. A dose-response relationship was also observed in that a 10 percent reduction in dietary fat was predicted to produce a 4- to 5-kg weight loss in an individual with a BMI of Most low-fat diets are also high in dietary fiber, and some investigators attribute the beneficial effects of low-fat diets to the high content of vegetables and fruits that contain large amounts of dietary fiber.

The rationale for using high-fiber diets is that they may reduce energy intake and may alter metabolism Raben et al. The beneficial effects of dietary fiber might be accomplished by the following mechanisms: 1 caloric dilution most high-fiber foods are low in calories and low in fat ; 2 longer chewing and swallowing time reduces total intake; 3 improved gastric and intestinal motility and emptying and less absorption French and Read, ; Leeds, ; McIntyre et al.

Dietary fiber is not a panacea, and the vast majority of controlled studies of the effects of dietary fiber on weight loss show minimal or no reduction in body weight LSRO, ; Pasman et al. Many individuals and companies promote the use of dietary fiber supplements for weight loss and reductions in cardiovascular and cancer risks.

Numerous studies, usually short-term and using purified or partially purified dietary fiber, have shown reductions in serum lipids, glucose, or insulin Jenkins et al.

Long-term studies have usually not confirmed these findings LSRO, ; Pasman et al. Current recommendations suggest that instead of eating dietary fiber supplements, a diet of foods high in whole fruits and vegetables may have favorable effects on cardiovascular and cancer risk factors Bruce et al.

Such diets are often lower in fat and higher in CHOs. Very-low-calorie diets VLCDs were used extensively for weight loss in the s and s, but have fallen into disfavor in recent years Atkinson, ; Bray, a; Fisler and Drenick, The VLCDs used most frequently consist of powdered formulas or limited-calorie servings of foods that contain a high-quality protein source, CHO, a small percentage of calories as fat, and the daily recommendations of vitamins and minerals Kanders and Blackburn, ; Wadden, The servings are eaten three to five times per day.

The primary goal of VLCDs is to produce relatively rapid weight loss without substantial loss in lean body mass.

To achieve this goal, VLCDs usually provide 1. VLCDs are not appropriate for all overweight individuals, and they are usually limited to patients with a BMI of greater than 25 some guidelines suggest a BMI of 27 or even 30 who have medical complications associated with being overweight and have already tried more conservative treatment programs.

Additionally, because of the potential detrimental side effects of these diets e. On a short-term basis, VLCDs are relatively effective, with weight losses of approximately 15 to 30 kg over 12 to 20 weeks being reported in a number of studies Anderson et al. However, the long-term effectiveness of these diets is somewhat limited.

Approximately 40 to 50 percent of patients drop out of the program before achieving their weight-loss goals. In addition, relatively few people who lose large amounts of weight using VLCDs are able to sustain the weight loss when they resume normal eating.

In two studies, only 30 percent of patients who reached their goal were able to maintain their weight loss for at least 18 months. Within 1 year, the majority of patients regained approximately two-thirds of the lost weight Apfelbaum et al.

In a more recent study with longer followup, the average regain over the first 3 years of follow-up was 73 percent. However, weight tended to stabilize over the fourth year. At 5 years, the dieters had maintained an average of 23 percent of their initial weight loss.

At 7 years, 25 percent of the dieters were maintaining a weight loss of 10 percent of their initial body weight Anderson et al. It appears that VLCDs are more effective for long-term weight loss than hypocaloric-balanced diets.

In a meta-analysis of 29 studies, Anderson and colleagues examined the long-term weight-loss maintenance of individuals put on a VLCD diet with behavioral modification as compared with individuals put on a hypocaloric-balanced diet.

They found that VLCD participants lost significantly more weight initially and maintained significantly more weight loss than participants on the hypocaloric-balanced diet see Table Almost any kind of assistance provided to participants in a weight-management program can be characterized as support services.

These can include emotional support, dietary support, and support services for physical activity. The support services used most often are structured in a standard way.

Other services are developed to meet the specific needs of a site, program, or the individual involved. With few exceptions, almost any weight-management program is likely to be more successful if it is accompanied by support services Heshka et al. However, not all services will be productively applicable to all patients, and not all can be made available in all settings.

Furthermore, some weight-loss program participants will be reluctant to use any support services. Psychological and emotional factors play a significant role in weight management.

Counseling services are those that consider psychological issues associated with inappropriate eating and that are structured to inform the patient about the nature of these issues, their implications, and the possibilities available for their ongoing management.

This intervention is less elaborate, intense, and sustaining than psychotherapy services. For example, it should be useful to help patients understand the existence and nature of a sabotaging household or the phenomenon of stress-related eating without undertaking continuing psychotherapy.

A counselor or therapist can provide this service either in individual or group sessions. These counselors should, however, be sufficiently familiar with the issues that arise with weight-management programs, such as binge eating and purging. Short-term, individual case management can be helpful, as can group sessions because patients can hear the perspective of other individuals with similar weight-management concerns while addressing their individual concerns Hughes et al.

Psychotherapy services, both individual and group, can also be useful. However, the costs of this type of service limits its applicability to many patients. Nevertheless, the value for individual patients can be substantial, and the option should not be dismissed simply because of cost.

Concerns about childhood abuse, emotional linkages to sustaining obesity fat-dependent personality , and the management of coexisting mental health problems are the kinds of issues that might be addressed with this type of support service.

The individual therapist can structure the format of the therapy but, as with counseling services, the therapist should be familiar with weight-management issues.

Nonprofessional patient-led groups and counseling, such as those available with organized programs like Take Off Pounds Sensibly and Overeaters Anonymous, can be useful adjuncts to weight-loss efforts. These programs have the advantages of low cost, continuing support and encouragement, and a semi-structured approach to the issues that arise among weight-management patients.

Their disadvantage is that, since the counseling is nonprofessional in nature, the programs are only as good as the people who are involved.

These peer-support programs are more likely to be productive when they are used as a supplement to a program with professional therapists and counselors. In Overeaters Anonymous, a variant of these groups is a sponsor-system program that pairs individuals who can help one another.

Certain commercial programs like Weight Watchers and Jenny Craig can also be helpful. Since commercial groups have their own agenda, caution must be exercised to avoid contradictions between the advice of professional counselors and that of the supportive commercial program.

Since the counselors in commercial programs are not likely to be professionals, the quality of counseling offered by these programs varies with the training of the counselors. Many communities offer supplemental weight-management services.

Educational services, particularly in nutrition, may be provided through community adult education using teaching materials from nonprofit organizations such as the American Heart Association, the American Diabetes Association, and government agencies FDA, National Institutes of Health, and U.

Department of Agriculture. Many community hospitals have staff dietitians who are available for out-patient individual counseling Pavlou et al. However, the military's TRICARE health services contracts would need to be modified to include dietitian services from community hospitals or other community services since these contracts do not currently include medical nutrition therapy and therefore dietitian counseling.

The family unit can be a source of significant assistance to an individual in a weight-management program. For example, program dropout rates tend to be lower when a participant's spouse is involved in the program Jeffery et al.

With simple guidance and direction, the involvement of the spouse as a form of reinforcement rather than as a source of discipline and monitoring can become a resource to assist in supporting the participant. However, individual family members or the family as a group can become an obstacle when they express reluctance to make changes in food and eating patterns within the household.

Issues of family conflict become more complex when the participants are children or adolescents or when spouses are reluctant to relinquish status quo positions of control. A variety of Internet- and web-related services are available to individuals who are trying to manage their weight Davison, ; Gray and Raab, ; Riva et al.

As with any other Internet service, the quality of these sites varies substantially Miles et al. An important role for weight-management professionals is to review such sites so they can recommend those that are the most useful.

The use of e-mail counseling services by military personnel who travel frequently or who are stationed in remote locations has been tested at one facility; initial results are promising James et al. The use of web-based modalities by qualified counselors or facilitators located at large military installations would extend the accessibility of such services to personnel located at small bases or stationed in remote locations.

Support is also required for military personnel who need to enhance their levels of physical fitness and physical activity. All branches of the services have remedial physical fitness training programs for personnel who fail their fitness test, but support is also needed for those who need to lose weight and for all personnel to aid in maintaining proper weight.

Support services should include personnel, facilities, and equipment, and should provide practical advice on how to begin and progress through physical training routines including proper use of training equipment and how to prevent musculoskeletal injuries , as well as advice on when and how to eat in conjunction with physical activity demands.

Success in the promotion of weight loss can sometimes be achieved with the use of drugs. Almost all prescription drugs in current use cause weight loss by suppressing appetite or enhancing satiety. One drug, however, promotes weight loss by inhibiting fat digestion.

To sustain weight loss, these drugs must be taken on a continuing basis; when their use is discontinued, some or all of the lost weight is typically regained.

Therefore, when drugs are effective, it is expected that their use will continue indefinitely. For maximum benefit and safety, the use of weight-loss drugs should occur only in the context of a comprehensive weight-loss program.

In general, these drugs can induce a 5- to percent mean drop in body weight within 6 months of treatment initiation, but the effect can be larger or smaller depending on the individual. As with any drug, the occurrence of side effects may exclude their use in certain occupational contexts.

Recognition that weight-related diseases, such as diabetes and hypertension, occur in individuals with BMI levels below 25, and that weight loss improves these conditions in these individuals, suggests that indications for weight-loss drugs need to be individualized to the specific patient.

A number of hormonal and metabolic differences distinguish obese people from lean people Leibel et al. Weight loss alters metabolism in obese individuals, limiting energy expenditure and reducing protein synthesis. This alteration suggests that the body may attempt to maintain an elevated body weight.

The facts that genetics might play a role in hormonal and metabolic differences between people and that weight loss alters metabolism imply that obesity is not a simple psychological problem or a failure of self-discipline.

Instead, it is a chronic metabolic disease similar to other chronic diseases and it involves alterations of the body's biochemistry.