**2. Multimodal lifestyle intervention for obesity management**

From practical point of view, the nonsurgical obesity-related disciplines are much easier to collaborate in a teamwork at any level of multidisciplinary structure. Diet, physical activity, and behavioral modification represent the cornerstone of nonsurgical management of obesity. Combination of these three modalities, which collectively seek to achieve a healthier and less obesogenic lifestyle, is the multimodal lifestyle intervention.

The barriers to a healthful lifestyle are numerous and complex but can be sorted in four levels: intrapersonal, interpersonal, community, and public policy levels. For adolescents, as an example, the main intra/interpersonal barriers were improper perception of the condition, lack of willingness, priority of studying, unsatisfactory weight loss results, and low self-esteem, while lack of family and cultural support, inadequate nutritional education, and scarcity of resources were the common community/public barriers [7]. Perspective of clinical nutrition, as a main medical specialty interested in obesity management, cannot combat these entire barriers resulting in high dropout and failure rates of obesity management. Clinical nutritionist with obesity interest should add some skills about physical activity prescription and behavioral modification to achieve better results. Therefore, integrated efforts of clinical nutritionist, physical activity trainer, and behavioral therapist could overcome much more of these barriers with better commitment and higher success rates of obesity management.

#### **2.1. Which specialties should share the responsibility?**

#### *2.1.1. Main medical specialties*

use of a complementary remedy showed small effects with unconvincing evidence in addition to some adverse effects [2]. Low success rates of nonsurgical treatments of obesity and inadequate results may not only result in a management failure but may increase severity of obesity [3]. Even in surgical solutions of obesity, one can find a promising rate of weight loss in short-term basis, but after few years, weight regained especially if not combined with lifestyle modifications such as compliance to dietary and physical activity prescriptions [4]. Accordingly, it can be concluded that single treatment modality is not sufficient for obesity management even with bariatric surgery. The multifactorial nature of obesity as a chronic disease emphasizes this theory. Combined different remedies for weigh loss such as diet plus physical activity achieved a synergistic result rather than using combined protocols in the

Teamwork management including different disciplines is increasingly emphasized in management of many chronic diseases. Depth of collaboration among allied disciplines created many levels of multimodal intervention. A multidisciplinary-team approach refers to the cooperation among members from different specialties, but each one stays within his boundaries and works independently or sequentially, each from his or her own disciplinaryspecific perspective (i.e., no overlap), in order to improve patient care. The second level is interdisciplinary approach, which harmonizes links between the different disciplines, in a coordinated and integrated fashion toward a common goal for the patient. The third level is transdisciplinary team in which specialists work jointly using a shared conceptual framework that draws together discipline-specific approaches, to address a common problem. Here, the traditional boundaries among different specialties were transcended [6]. Obesity is a good candidate for applying any of these levels for teamwork management because of its multifactorial nature, diversity in response to separate treatment approaches, and predisposition to

same remedy such as low-fat diet and low-carbohydrate diet [5].

118 Adiposity - Epidemiology and Treatment Modalities

multiple comorbidities belong to different medical specialties.

obesogenic lifestyle, is the multimodal lifestyle intervention.

**2. Multimodal lifestyle intervention for obesity management**

From practical point of view, the nonsurgical obesity-related disciplines are much easier to collaborate in a teamwork at any level of multidisciplinary structure. Diet, physical activity, and behavioral modification represent the cornerstone of nonsurgical management of obesity. Combination of these three modalities, which collectively seek to achieve a healthier and less

The barriers to a healthful lifestyle are numerous and complex but can be sorted in four levels: intrapersonal, interpersonal, community, and public policy levels. For adolescents, as an example, the main intra/interpersonal barriers were improper perception of the condition, lack of willingness, priority of studying, unsatisfactory weight loss results, and low self-esteem, while lack of family and cultural support, inadequate nutritional education, and scarcity of resources were the common community/public barriers [7]. Perspective of clinical nutrition, as a main medical specialty interested in obesity management, cannot combat these entire barriers resulting in high dropout and failure rates of obesity management. Clinical nutritionist with obesity interest should add some skills about physical activity prescription The first two components of multimodal lifestyle intervention were clinical nutrition and physical activity. Addition of physical activity augments diet-induced weight loss through many mechanisms. One study examined the total energy expenditure by doubly labeled water and resting metabolic rate by indirect calorimetry in 116 severely obese patients undergoing intervention with diet alone or diet plus physical activity (PA). The results were lower reduction in the daily total energy expenditure (−122 ± 319 vs. −376 ± 305 kcal day−1), elimination of the usual decrease of the activity-induced energy expenditure (83 ± 279 vs. −211 ± 284 kcal day−1), and greater weight loss (13.0 ± 7.0 vs. 8.1 ± 6.3 kg) in diet plus PA group vs. diet alone. Increased PA was associated with greater adherence to low-calorie prescriptions and maintenance of greater weight loss after 6 months [8]. Furthermore, combination of PA modalities such as aerobic training and resistance training adds more to the healthy eating lifestyle than one PA modality. A randomized, parallel-group clinical trial at communitybased exercise facilities in two Canadian cities examined 304 adolescents with obesity and revealed that resistance, aerobic, and combined training decreased total percent body fat and waist circumference in adolescents with obesity. Additionally, adherent cases with combined training might cause greater results than aerobic or resistance training alone [9]

Adding a new player to the obesity managing team such as behavioral modification/therapy raises the success rates and gives promising results not only in weight loss but also in body composition. Therefore, it is now accepted that behavioral therapy is an essential component of any adequate obesity managing team. Behavioral management includes many techniques such as goal setting, stimulus control, stress management, problem-solving procedures, selfmonitoring, reinforcement techniques, cognitive restructuring, rewarding changes in behavior, social and family support, and relapse anticipation/prevention training [10]. Detailed description of these techniques is out of scoop of this chapter. Another alternative psychological approach for obesity management was reported [11]. It is based on food dependency model of obesity. This model considers obesity as a form of addiction, similar to psychoactive substance abuse, that is, obesity is a combination of the inability to control eating and exercise behaviors to control body fat as a result of an addictive process produced by a vicious circle of distorted thinking and physiological disturbances. According to this model, recommendation for weigh loss included reasonable caloric restriction, gradual decrease of fat quantity in food, physical exercise, strategies for improving self-regulation of eating and exercise, and social/ family support [12]. A large number of clinical trials examined the effects of behavioral treatment on weight loss. Most of these trials structured group meetings weekly for the initial 3–6 months of treatment period, biweekly meetings later on up to 12 months, and then become monthly or bimonthly for the later phases of the study (up to 2 years). Group therapy may be more effective than individual treatment as it is less costly and provides a combination of empathy, social support, and healthy competition [13].

Another member of the team could enhance weight loss outcomes, which is adding a pharmacotherapy to previous approaches. Medications try either to modify the internal environment centrally or peripherally or to minimize the obesity-related physiological disturbances as a trial to predispose to a healthier internal environment. Orlistat, phentermine/topiramate, glucagon-like peptide-1 receptor agonists, lorcaserin, dipeptidyl peptidase-4 inhibitors, pramlintide, and dapagliflozin are available medications of variable adjuvant effects, when integrated with the multimodal lifestyle intervention yield more success [14]. In the future, novel therapeutic targets should extend beyond appetite control to include new strategies, such as taste preferences (e.g., Umami), energy expenditure, gut microbiota, bile acid signaling, preservation of β-cell function and hepatic glucose output, and so on.

#### *2.1.2. Other disciplines*

Complementary and alternative medicine (CAM) is defined as a group of varied medical and healthcare systems, practices, and products that are not considered to be part of any current Western healthcare system [15]. CAM included a wide range of remedies that were used in obesity management such as herbal supplements, acupuncture, and noninvasive body-contouring devices in addition to homeopathy, yoga therapy, relaxation techniques, massage, and chiropractic medicine. Despite the lack of a strong evidence about efficacy and safety, CAM is widely used especially at private centers and as a folk medicine. The positive results may appear more with mild degrees of obesity [2]. For acupuncture as an example, a meta-analysis published in 2009 [16] investigated the randomized controlled trials (RCTs) for acupuncture compared either with placebo-controlled or with dietary intervention for obesity management and revealed that acupuncture is an effective modality for obesity treatment. However, the amount of evidence is not highly convincing because of the poor methodological quality of trials reviewed. Addition of one or more remedies of CAM to the multimodal lifestyle intervention might produce more success in obesity cure. This evident in a study performed a retrospective analysis of patients attending a 13-week weight loss program consisting of chiropractic/spinal manipulative therapy in addition to nutritional intervention, physical activity, and one-on-one counseling. The results were statistically and clinically significant as regarding changes in weight and BMI. This might provide supporting evidence on the effectiveness of a multimodal approach to weight loss supplemented with chiropractic therapy [17].

#### **2.2. Where? or In which setting?**

#### *2.2.1. Obesity multidisciplinary teams (OMDTs)*

Construction of multidisciplinary, interdisciplinary, or transdisciplinary centers for obesity management is necessary for augmentation of success rates of lifestyle intervention. The National Institute of Health and Care Excellence (NICE) has recommended that multidisciplinary teams (MDTs) should be used in the treatment of complex obesity. In each hospital, OMDT should consist of a bariatric physician with a specialist interest in obesity as a leader, a registered dietitian, a clinical/counseling psychologist, a specialist nurse, and an access to a physical therapist/exercise physiologist. MDT weight management services should be delivered in the secondary care setting where bariatric physician (such as an endocrinologist or a physician nutrition specialist) can assess etiology, severity of obesity, and its related comorbidities through the medical history and physical examination. The physician will then prescribe appropriate antiobesity drugs or medication for associated comorbidities. Patient should be referred or shifted to other members of OMDT. A dietitian is required to assess the dietary habits of the patient and to tailor an individualized management plan that will aid sustainable weight loss. The role of a psychologist is to identify the psychosocial factors that contributed to the body weight and the factors that maintain the problem and prevent making meaningful lifestyle changes. Then he recommends a plan for how these factors can be managed either by a psychological support within the MDT service or by referring them to an appropriate psychiatric subspecialty. A physical therapist is essential to assess the patient's physical capability and prescribe the appropriate plan of physical activity. The specialist nurse is required to assist with medical assessments, provide advice regarding comorbidity management, and assist in the administration and scoring of dietary or mental questionnaires [18], see **Figure 1**.

**Figure 1.** Construction and job specification of the obesity multidisciplinary team.

#### *2.2.2. Primary healthcare setting*

Another member of the team could enhance weight loss outcomes, which is adding a pharmacotherapy to previous approaches. Medications try either to modify the internal environment centrally or peripherally or to minimize the obesity-related physiological disturbances as a trial to predispose to a healthier internal environment. Orlistat, phentermine/topiramate, glucagon-like peptide-1 receptor agonists, lorcaserin, dipeptidyl peptidase-4 inhibitors, pramlintide, and dapagliflozin are available medications of variable adjuvant effects, when integrated with the multimodal lifestyle intervention yield more success [14]. In the future, novel therapeutic targets should extend beyond appetite control to include new strategies, such as taste preferences (e.g., Umami), energy expenditure, gut microbiota, bile acid signal-

Complementary and alternative medicine (CAM) is defined as a group of varied medical and healthcare systems, practices, and products that are not considered to be part of any current Western healthcare system [15]. CAM included a wide range of remedies that were used in obesity management such as herbal supplements, acupuncture, and noninvasive body-contouring devices in addition to homeopathy, yoga therapy, relaxation techniques, massage, and chiropractic medicine. Despite the lack of a strong evidence about efficacy and safety, CAM is widely used especially at private centers and as a folk medicine. The positive results may appear more with mild degrees of obesity [2]. For acupuncture as an example, a meta-analysis published in 2009 [16] investigated the randomized controlled trials (RCTs) for acupuncture compared either with placebo-controlled or with dietary intervention for obesity management and revealed that acupuncture is an effective modality for obesity treatment. However, the amount of evidence is not highly convincing because of the poor methodological quality of trials reviewed. Addition of one or more remedies of CAM to the multimodal lifestyle intervention might produce more success in obesity cure. This evident in a study performed a retrospective analysis of patients attending a 13-week weight loss program consisting of chiropractic/spinal manipulative therapy in addition to nutritional intervention, physical activity, and one-on-one counseling. The results were statistically and clinically significant as regarding changes in weight and BMI. This might provide supporting evidence on the effectiveness

of a multimodal approach to weight loss supplemented with chiropractic therapy [17].

Construction of multidisciplinary, interdisciplinary, or transdisciplinary centers for obesity management is necessary for augmentation of success rates of lifestyle intervention. The National Institute of Health and Care Excellence (NICE) has recommended that multidisciplinary teams (MDTs) should be used in the treatment of complex obesity. In each hospital, OMDT should consist of a bariatric physician with a specialist interest in obesity as a leader, a registered dietitian, a clinical/counseling psychologist, a specialist nurse, and an access to a physical therapist/exercise physiologist. MDT weight management services should be delivered in the secondary care setting where bariatric physician (such as an endocrinologist or a

ing, preservation of β-cell function and hepatic glucose output, and so on.

*2.1.2. Other disciplines*

120 Adiposity - Epidemiology and Treatment Modalities

**2.2. Where? or In which setting?**

*2.2.1. Obesity multidisciplinary teams (OMDTs)*

Primary healthcare (PHC) practitioners are encouraged to screen all adults for obesity and to offer nutritional education and behavioral counseling to cases with obesity. Training of PHC practitioners on implementation of the basic components of multimodal lifestyle intervention especially dietary, physical activity, and behavioral counseling is mandatory. In the year 2006, the National Heart, Lung, and Blood Institute (NHLBI) funded practice-based opportunities for weight reduction (POWER) trials for this purpose [19]. Three clinical trials [20–22] proved that PHC practitioners produced mean weight losses ranged from 3.6 to 9.7 at 6 to 12 months when they provided a brief behavioral counseling to obese patients in their daily practices. A fourth study randomly enrolled overweight 113 women into a dietitian-led intervention, a dietitian-led intervention plus meal replacements, or a PHC intervention with meal replacements. Participants were instructed to attend brief every-other-week visits with their primary care physician or nurse. After 1 year, adherent cases (65%) in PHC group lost weight slightly more than dietitian-led group (4.3% vs. 4.1% of initial weight). However, participants in the dietitian-led plus meal replacements group lost 9.1%, that is, PHC intervention using meal replacements was as effective as the traditional dietitian-led group intervention not using meal replacements [23].

#### *2.2.3. Via telephone or the internet*

Multimodal lifestyle intervention is now being delivered by the telephone or Internet (rather than in face-to-face setting). Web-based programs such as Weight Watchers and Nutrisystem allow individual to record their weight, dietary intake, and physical activity online and to receive colorful dietary regimens, tips for physical activity, and behavioral modification, together with graphic displays of weight changes. Even in some programs, a personalized intervention by a lifestyle specialist can be offered. Internet intervention generally produces mean weight losses about one-third of the traditional face-to-face programs and about three times of the self-help controls. These commercial interventions proved their effects via RCTs against self-help controls [13, 19].
