**3. Outcomes of multimodal lifestyle intervention**

Outcomes of the multimodal lifestyle intervention are still inferior to surgical results. However, it is increasingly promising especially if implemented via OMDT. Clinical studies comparing intensive multimodal lifestyle intervention with bariatric surgery provide a convincing evidence about the growing effect of nonsurgical solutions of obesity. A randomized controlled, clinical trial with a 2-year intervention aimed to compare the efficacy of the three levels of obesity intervention, that is, conventional obesity therapy (COT), intensive multimodal obesity management including behavioral therapy (IMOM), and bariatric surgery (BS) as regarding changes in body weight and metabolic parameters in morbidly obese patients. IMOM group resulted in a greater percentage of weight loss than COT patients (−11.3% vs. −1.6%; *P* < 0.0044). Furthermore, 31.4% of patients in the IMOM group became non-morbidly obese within six months of intervention, and at the end of the study, they increased to 44.4%. By comparison with BS group, percentage weight loss grew from 5% for COT group to 38% for IMOM from surgical achievement, that is, percentage of weight loss in IMOM achieved more than one-third of the results of bariatric surgery without complication of surgery. Accordingly, IMOM could be an alternative therapy to patients with obesity, who cannot tolerate bariatric surgery [24].

Look AHEAD study is an interesting 8-year randomized clinical trial. They investigated the effects of intentional weight loss via intensive multimodal lifestyle intervention that included behavioral therapy vs. usual care (education and medication of diabetes), on cardiovascular morbidity and mortality in 5145 overweight/obese adults with type 2 diabetes. Dropout rate was only 12%, and in adherent cases, a clinically significant weight loss (≥5%) at year 8 occurs in 50% of patients with type 2 diabetes [25]. Furthermore, they proved that severely obese participants had similar adherence, percentage of weight loss, and improvement in CVD risk compared with less obese participants, indicating that multimodal lifestyle intervention including behavioral therapy should be considered an effective option for this high-risk category [26].

A recent meta-analysis assessed the impact of lifestyle interventions including a physical activity plan on health outcomes of patients with class II and class III obesity. After the analysis of 56 articles, they concluded that lifestyle interventions including a PA plan can improve weight and various cardiometabolic risk factors in class II and class III obese individuals [27]. By shifting to prospective studies, Karlsen et al. [28] reported that the predictors of weight loss after intensive multimodal lifestyle intervention for one year in morbidly obese patients were excess weight loss at 12 weeks, baseline mental health-related quality of life, occupational status, and age.

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

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

Outcomes of the multimodal lifestyle intervention are still inferior to surgical results. However, it is increasingly promising especially if implemented via OMDT. Clinical studies comparing intensive multimodal lifestyle intervention with bariatric surgery provide a convincing evidence about the growing effect of nonsurgical solutions of obesity. A randomized controlled, clinical trial with a 2-year intervention aimed to compare the efficacy of the three levels of obesity intervention, that is, conventional obesity therapy (COT), intensive multimodal obesity management including behavioral therapy (IMOM), and bariatric surgery (BS) as regarding changes in body weight and metabolic parameters in morbidly obese patients. IMOM group resulted in a greater percentage of weight loss than COT patients (−11.3% vs. −1.6%; *P* < 0.0044). Furthermore, 31.4% of patients in the IMOM group became non-morbidly obese within six months of intervention, and at the end of the study, they increased to 44.4%. By comparison with BS group, percentage weight loss grew from 5% for COT group to 38% for IMOM from surgical achievement, that is, percentage of weight loss in IMOM achieved more than one-third of the results of bariatric surgery without complication of surgery. Accordingly, IMOM could be an alternative therapy to patients with obesity, who cannot

Look AHEAD study is an interesting 8-year randomized clinical trial. They investigated the effects of intentional weight loss via intensive multimodal lifestyle intervention that included behavioral therapy vs. usual care (education and medication of diabetes), on cardiovascular morbidity and mortality in 5145 overweight/obese adults with type 2 diabetes. Dropout rate was only 12%, and in adherent cases, a clinically significant weight loss (≥5%) at year 8 occurs in 50% of patients with type 2 diabetes [25]. Furthermore, they proved that severely obese participants had similar adherence, percentage of weight loss, and improvement in CVD risk compared with less obese participants, indicating that multimodal lifestyle intervention including behavioral therapy should be considered an effective option for this high-risk category [26].

meal replacements [23].

*2.2.3. Via telephone or the internet*

122 Adiposity - Epidemiology and Treatment Modalities

against self-help controls [13, 19].

tolerate bariatric surgery [24].

**3. Outcomes of multimodal lifestyle intervention**

Data from pediatric studies are also promising. Morano et al. [29] designed a 6-month multimodal lifestyle intervention for children (ages 10–12 years) with obesity, incorporating school- and family-based components, nutritional education, fun-type physical activities, and exercise training. The results were significant reduction in body mass index z-score, body fat percentage, arm and waist circumferences, and skinfold thickness (for all *P* < 0.05), in addition to improvement of actual and perceived physical abilities, physical activity enjoyment, psychosocial health-related quality of life, and dietary pattern. This indicates the importance of combined dietary-physical activity-behavioral interventions in children with overweight and obesity. Meta-analysis of 64 pediatric and adolescent RCTs (5230 participant) including lifestyle interventions focused on physical activity and sedentary behavior (12 studies), diet only (6 studies), and multimodal interventions concentrated on behavioral modification/therapy (36 studies), and antiobesity drug interventions (metformin, orlistat, and sibutramine) were found in 10 studies. The studies varied greatly in design, outcome measurements, and methodological quality. The authors concluded that combined behavioral lifestyle interventions compared to standard care or self-help can produce a significant and clinically meaningful weight reduction in children and adolescents. However, the limited quality data cannot recommend one treatment program to be superior over another [30].

Efforts should be directed toward explanation and extraction of the underlying mechanisms of proper lifestyle intervention of obesity. As a trial, many studies examined body compositional changes during and after intervention. I have one published article about this issue, where a cohort of adult men with overweightness and obesity underwent to a multicomponent lifestyle intervention including dietary restriction, gradual physical plan, and techniques of behavioral modification for 12 months. In regards to the short-term changes in the body composition, there were a significant loss of fat-free mass (FFM), fat-free mass index (FFMI), and total body water (TBW) in obesity group rather than overweight group. This indicates that patients with obesity lose water and fat-free tissues together with fat loss in the early weeks of multimodal lifestyle intervention for obesity management. On the other hand, long-term body compositional changes after 6 to 12 months showed progressive significant reduction of weight, BMI, waist circumference, percent body fat, fat mass, and fat mass index throughout the study, in addition to preservation of FFM, FFMI, and TBW [31]. Unpublished data revealed also a significant reduction of estimated visceral fat area and improvement of lipid panel. A new meta-analysis of RCTs, which assessed the effect of caloric restriction and exercise training on bone mineral density (BMD), was published [32]. It proved that diet-induced weight reduction led to reduction of BMD at the hip and lumbar spine, while exercise-induced weight loss did not. Furthermore, a running RCT investigating body composition and bone mass changes among children undergoing multimodal lifestyle intervention was started by Cohen et al. [33]. They designed a RCT for 6- to 8-year-old children with overweightness or obesity, where participants were randomized to a family-centered intervention including nutritional education, physical activity, and behavioral control vs. standard treatment.

Unpredicted outcomes are a common feature of lifestyle intervention for chronic diseases especially for obesity. Karlsen et al.'s study [28] tried to report some predictors of weight loss after intensive multimodal lifestyle intervention in morbidly obese patients (see above). In Abulmeaty [31] study comparison of the basal characteristics adherent with non-responding and dropped out cases revealed that cases with high percent body fat were more prone to dropping out. Furthermore, Suchánek et al. [34] reported that body composition changes in adult females after lifestyle intervention were influenced by the NYD-SP18 gene polymorphism, where overweight/obese female carriers of the NYD-SP18 rs6971091 GG genotype exhibited a more beneficial response to the intensive lifestyle intervention than others.

Another significant limitation of multimodal lifestyle intervention is high rates of dropout. One systemic review searched the literature to find an answer of that question "what are the dropout rates in lifestyle intervention programs for overweight and obese infertile women?" Ten out of studied fifteen articles reported dropout rates. The median dropout rate was 24% (ranged from 0% to 31%). They also concluded that women who drop out lose less weight and have lower spontaneous pregnancy chances than adherents [35]. About 64% is another published rate of dropout from Kuwaiti adult males and females with chronic diseases including diabesity [36]. They also reported the main causes of dropout from dietary intervention, which included unwillingness (48.6%), difficulty adhering to a diet different from that of the family (30.2%), and social meetings (13.7%). The main reasons of exercise dropout were lack of time (39.0%), co-morbid conditions (35.6%), and bad weather conditions (27.8%). The factors interfering with adherence to lifestyle measures were use of cars more than walking (83.8%), traditional fatty food, (79.9%), daily stress (70.7%), high frequency of social meetings (59.6%), high consumption of fast food (54.5%), and the presence of house cleaners (54.1%).
