Intensive Lifestyle Interventions as a Measure to Reduce the Rising Obesity Cases

Dinah M. Limiri
Freelance writer, Maua, Kenya
Correspondence to: diana.mwendwa34@gmail.com

DOI: https://doi.org/10.70389/PJPH.100013

Additional information

• Ethical approval: N/a
• Consent: N/a
• Funding: No industry funding
• Conflicts of interest: N/a
• Author contribution: Dinah M. Limiri – Conceptualization, Writing – original draft, review and editing
• Guarantor: Dinah M. Limiri
• Provenance and peer-review:
  Commissioned and externally peer-reviewed
• Data availability statement: N/a

Keywords: Obesity, Intensive lifestyle interventions, Diet, Physical activity, Behavior therapy.

Peer Review
Received: 28 August 2024
Revised: 18 October 2024
Accepted: 19 October 2024
Published: 28 October 2024

Introduction

The number of global obesity cases has risen exponentially over the decades. For instance, in 1980, the total number of overweight and obesity cases was 921 million. However, by 2013, these numbers had almost tripled up to 2.1 billion.¹ In 2022, these numbers had risen by an additional 400 million to a total of 2.5 billion cases.² Things are expected to get worse as projections show that the numbers will reach 4 billion by 2035.³ A number of factors are making these numbers surge. Although historically obesity has been attributed to eating patterns, research shows that different factors, namely, social determinants of health, are contributing to this surge.² There are a number of interrelated factors such as a person’s living and built environment, income level, education, and working life conditions which increase the likelihood of weight gain. Due to the interrelated nature of these factors, different measures are needed to successfully address the obesity problem.

Lifestyle modifications remain a cornerstone in fighting the obesity epidemic. Particularly, intensive lifestyle interventions are recommended as effective to address the rising obesity numbers. Intensive lifestyle interventions are a combination of measures such as a reduced-calorie diet, increased physical activity, and behavior therapy all of which are done with the intention of reducing weight.⁴ According to the American Heart Association, American College of Cardiology, and Obesity Society Guideline for the Management of Overweight and Obesity in Adults, individuals can engage in these interventions to reduce weight.⁵ These comprehensive interventions are recommended for a duration of at least six months under the supervision of an interventionist (a trained personnel).⁵ Comprehensive lifestyle interventions are effective in weight loss.^5–7 They also reduce the likelihood of complications such as type 2 diabetes and cardiovascular disease.^7,8 Incorporating these interventions to treat obesity cases shows a lot of promise in reducing obesity-related costs and comorbidities. This paper reviews current evidence on the efficacy of intensive lifestyle interventions as a measure to reduce the rising obesity cases. The paper includes recent statistics on the global obesity prevalence, different components of intensive lifestyle interventions how they work to reduce weight, and whether they are effective in weight management.

Obesity Prevalence

Obesity remains a significant public health challenge globally, despite years of research in finding effective measures to address the problem. Approximately 2.5 billion adults globally are affected by overweight and obesity, according to WHO 2022 statistics.² Children and adolescents are another demographic that is reporting a high number of overweight and obesity cases with 390 million cases reported in 2022.² Of these, 160 million were obese.² The rising obesity cases represent an upward trend with the cases being reported globally rising exponentially in the last four decades. In 1980, there were approximately 921 million people affected by obesity and overweight across the globe.¹ The numbers rose to 2.1 billion cases in 2013 and 2.5 billion in 2022, respectively.^1,2 Projections show that these numbers are likely to rise to 4 billion by 2035.³ Table 1 shows obesity and overweight trends over the years.

Table 1: Global Obesity and Overweight Trends 1980-2035 (Approximate Numbers in Millions).
	1980	2013	2022	2035
Number of overweight and obesity cases in millions (BMI ≥ 25 kg/m²)	921	2,100	2,500	4,005 (including children over 5 years)
Number of obesity cases in millions (BMI ≥ 30 kg/m²)	170	600	890	1,914
Percentage of population with obesity and overweight (BMI ≥ 25 kg/m²)	29.3	39	43	51
Percentage of population with obesity (BMI ≥ 30 kg/m²)	6.35	13	16	24

Trends also show that obesity is increasing by region. Recent data show changing trajectories of obesity cases in terms of sociodemographic index (SDI) with countries with high SDI levels reporting rapid increase in obesity cases in the last decade.⁹ Predominantly, the highest number of obesity cases were reported in countries with low to medium SDI levels with factors such as lack of physical activity, unhealthy eating habits, and sedentary lifestyle contributing to these cases. However, recent statistics indicate that these trends are changing, and countries with high SDI are also reporting high numbers. The World Obesity Atlas report projects that obesity cases will increase across regions by 2035. From 68 million in 2020 to 182 million in 2035 in sub-Saharan Africa to 246 million in 2020 to 395 million in 2035 across the Americas.³ Across the Americas, the United States is the most affected with 2 in 5 adults across the country living with obesity.¹⁰ Between 2017 and 2018, the obesity prevalence had risen to 42.4%.¹¹ Obesity cases are also projected to rise in all other regions, as summarized in Table 2.

Table 2: Obesity Projections.
Region	Obesity numbers in 2020 (millions)	Projected obesity numbers in 2035 (millions)
African region (sub-Saharan Africa)	68	182
Americas (North, Central, and South America)	246	395
Mediterranean (North Africa and Middle East)	106	212
European	192	263
South-East Asia	79	202
Western Pacific	120	272

When it comes to gender, obesity prevalence is generally higher among women than men across all age groups with the most affected age groups being women aged 60–64 and men aged 50–54.⁹ For children and adolescents who are between 5 and 19 years, more boys (103 million) than girls (72 million) were obese.³ 390 million children and adolescents were overweight while 160 million were obese in 2022.² In the US, for instance, 1 in every 5 children, representing 14.7 million children, is living with obesity.¹² The rising obesity cases necessitate a number of lifestyle interventions to address the problem. As a cornerstone of treating obesity, these interventions have shown to be instrumental in helping people to manage their weight which makes them instrumental in the fight against the rising obesity numbers.^4,7

Intensive Lifestyle Interventions

Diet

Diet is an essential component of lifestyle intervention that has been proven to induce weight loss. Because eating patterns are one of the drivers of the recent obesity surge, diet is an important aspect of lifestyle modification. A calorie restriction diet is clinically proven to contribute to weight loss with Obesity Guidelines suggest a deficit of 500–750 kcal/day can result in up to 0.5–0.75 kg loss per week.⁵ Different studies recommend reducing energy density as effective for weight loss.^13–15 Consuming food that has low energy density leads to weight loss because it reduces overall energy intake. Different energy-restricted diets such as food that is low in fat, low in carbohydrates, and high in protein have been shown to have positive effects.¹⁶ According to the guidelines, 15–20% of daily calories should be drawn from protein, 20–35% from fat of which no more than 10% should be from saturated fats, and the remaining calories should be drawn from carbohydrates including fruits and vegetables.¹⁶ The Guideline also recommends limitation of calorie intake from foods that contain added sugars, saturated fats, and sodium intake.¹⁶ Instead, individuals should eat more varieties of nutrient-dense foods to achieve the daily recommended caloric intake.

The recommendation to consume low-fat, low-carbohydrate, and high-protein diets is a representation of the shifting patterns from lifestyle modification programs that mainly recommended consuming more carbohydrates and less fat as the necessary ingredients for weight loss.⁴ As research advances, different dietary approaches are coming up and proving to be vital in managing weight.⁷ Examples of such dietary approaches are Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets. The Mediterranean diet is mainly plant-based, with foods such as vegetables, legumes, fruits, wholegrain breads and cereals, and nuts and seeds making up most of the diet. It also comprises seafood, dairy foods, and olive oil. The DASH diet also comprises fruits and vegetables, with great emphasis being placed on consuming food that has less healthy fats. The diet recommends up to 9–12 servings of fruits and vegetables per day.¹⁷ Research has shown that both of these diets are effective for weight loss.^18,19 The diets also reduce obesity-related complications.²⁰ Although macronutrient composition and dietary approaches are important in weight management, energy density remains crucial in lowering obesity cases. As such, it is important to encourage individuals to have eating patterns that promote lower energy density intake to achieve the goal of weight loss. According to Ledikwe et al.¹⁵ the more energy density reduces, the more weight is lost. Maintaining these eating patterns in the long term can ensure this weight is not regained.^21,22 A low-energy dietary pattern in this case mainly comprised a diet with high fruit and vegetable intake.¹⁵

Physical Activity

Another component of intensive lifestyle interventions is physical activity.^23,24 Physical activity is important because it can improve overall health outcomes.²⁵ The WHO Guidelines on Physical Activity recommend different frequencies, intensities, and durations of physical activity for different age groups.²⁶ For instance, for children between 5 and 19 years, it is necessary to have 60 minutes of exercise per day across the week.²⁶ For adults (18–64 years), the guideline recommends at least 150–300 minutes across the week. If it is intense aerobic physical activity, the guideline recommends 75–150 minutes across the week.²⁶ Vigorous aerobic activity in this case can include activities such as cycling or walking. Physical activity is recommended as one of the lifestyle interventions that can help to reduce weight because it encourages energy expenditure.²⁷ The energy intake and energy expenditure hypothesis can provide a better understanding of why obesity numbers are increasing. Based on the hypothesis, energy intake should not exceed energy expenditure because it contributes to weight gain.^28,29 Instead, energy expenditure should exceed energy intake if weight loss is to happen. However, with the modern lifestyle that mainly comprises sedentary behavior and consumption of foods high in calories, weight gain and obesity are likely to persist. Although physical activity alone can contribute to weight loss, the effects are mainly short-term, which necessitates a combination with other measures such as calorie restriction.²⁴ For individuals who are not able to get the recommended amounts of physical activity per week, some researchers recommend multiple brief bouts of physical activity each day.⁴ For instance, engaging in 10-minute walks can have numerous benefits for individuals living with obesity.

Behavior Therapy

Although interventions such as restricting caloric intake and increasing physical activity are important in helping obese patients lose weight, behavior therapy is required to reinforce these changes. Research has shown that behavior therapy provides the necessary tools that can help patients to change behavior.³⁰ Behavior therapy as an important lifestyle intervention in weight management for obesity patients is founded on evidence that individuals become and remain obese because of modifiable behaviors and habits.³¹ As such, changing these behaviors can result in sustaining the weight lost. Some common strategies that can be used to facilitate behavior modification are making people more aware of the factors that trigger the problematic behavior, in this case, problematic eating and inadequate exercise, identifying how people feel about weight issues and trying to rectify that, providing the needed support that encourages behavior change, and having realistic goals to achieve the desired change.³² Overall, the primary aim of behavioral therapy in weight management is to alter habits that foster weight gain such as eating food with high calorie intake and reduced participation in physical activity.

Behavior therapy follows the principles of classical conditioning, with eating being prompted by food-related cues.³¹ Behavioral treatment helps an individual to identify the cues that trigger bad eating habits and learn new responses that can help to address these cues. Therefore, behavioral therapy in the management of obesity is informed by assumptions that individuals who are obese have inappropriately adapted to maladaptive behaviors and they can be changed through interventions that lead to positive outcomes.³⁰ Different techniques can be used to facilitate behavior change for obese patients. One of these is self-monitoring. Research has shown that self-monitoring leads to effective outcomes when it comes to weight control.³³ Self-monitoring entails the recording of calorie intake and physical activities.³³ It can be done using food diaries and activity logs. These records provide crucial information that can be used to monitor one’s progress towards weight loss goals. Examples of information contained in the diaries and activity logs are food content, daily calorie intake, body weight, type and duration of physical activity, body mass, and nutrient groups.³⁴ An individual can review the records regularly to evaluate their progress towards meeting the desired goal. Self-monitoring is effective in weight management because it makes an individual more self-aware of how their behaviors are benefiting or affecting their effort to lose weight.

Goal-setting is another technique that can be used to facilitate behavior change in individuals living with obesity. Goal-setting can be collaboratively done with the interventionist where the behavior to be changed is clearly identified and goals to make this change possible clearly identified.⁷ Just like any other goals in healthcare, these goals should be specific, reasonable, and attainable. In addition to setting dietary intake and weight loss goals, patients can also set goals for physical activity.³⁵ For instance, targeting 30 minutes of daily moderate exercise can lead to positive outcomes when it comes to achieving weight loss goals.

An additional technique of behavioral therapy that has been shown to have a positive impact is stimulus control. Stimulus control involves making changes to eating and activity-related cues in a patient’s environment. For instance, having too much junk food at home can encourage unhealthy eating habits. The patient uses cognitive techniques such as classical and operant conditioning to control these cues and attain the desired behavior. Research has shown that controlling these cues can lead to positive outcomes.^30,34,36 The aim is to create an environment that fosters positive behavior change and attains the set weight management goals. Other behavior techniques and interventions that can be used to improve outcomes for obese patients are problem-solving, providing patients with the necessary social support, alternate behaviors, stress management, and behavioral substitution.³⁴ All these interventions have been shown to have different success rates when it comes to managing obesity, but the main outcome is weight loss, as shown in Figure 1.

Effectiveness of Intensive Lifestyle Interventions in Weight Management

Different studies and clinical trials show these interventions are effective in weight loss which means they can be used to manage the rising obesity cases.^{18,19,23,37–39} Diets that contain low carbohydrate content are more effective than conventional diets when it comes to weight loss.³⁷ In one study, individuals who were on the low-carbohydrate diet lost about (5.1 ± 8.7 kg) which was higher than (−3.1 ± 8.4 kg) for those who were on the conventional diet.³⁷ Foster et al.³⁸ established similar findings with the low-carbohydrate group losing (−6.8 ± 5.0 kg) and the conventional diet losing (−2.7 ± 3.7 kg) at three months. Shai et al.¹⁸ established that individuals who were on the low-carbohydrate diet reported losing the highest amount of weight at 4.7 kg with the Mediterranean diet group losing 4.4 kg and the low-diet 2.9 kg. Similarly, Samaha et al.⁴⁰ with the low-carbohydrate diet group losing (−5.8 ± 8.6 kg) and the fat-restricted diet (−1.9 ± 4.2 kg).

Other types of diets, such as the Mediterranean diet, DASH diet, and reducing dietary energy density, are also effective.^15,19 According to Jenny et al.,¹⁵ the DASH diet group reported more energy intake but greater loss of weight than the advice group. Similarly, Esposito et al.¹⁹ established that the Mediterranean group reported losing more weight compared to the control diet group. From the reviewed studies, it is evident that different diet approaches can help individuals with obesity in weight management. Though for most of the interventions, the effects are short-term, these approaches can be combined with other measures such as physical activity and behavioral therapy for better outcomes.

Just like diet, physical activity is an effective measure that can help obese patients manage their weight.^23,39,41 Goodpaster et al.²³ established that one year of intensive lifestyle intervention that included physical activity resulted in weight loss. According to Ross et al.,³⁹ exercise-led interventions made individuals lose up to 7.5 kg. Similarly, Donnelly et al.⁴¹ noted that obese and overweight women lost weight when they were enrolled in aerobic exercises. High-intensity training and a Mediterranean diet can also improve glycemic control and insulin resistance for patients who are struggling with obesity.⁴² Other benefits that have been associated with physical activity for obese patients are improvement in cardiovascular fitness and fat decrease.³⁹ Improving cardiovascular fitness, glycemic control, insulin resistance, and decreasing fat mass is important for obese patients because it reduces related risks. To sustain weight loss using diet approaches and physical activity, behavior therapy is needed. Behavior therapy helps individuals to modify behavior which is necessary to achieve the desired outcomes. Different studies have shown that behavior therapy is important in weight loss and weight management.^36,43 Befort et al.⁴³ established that behavior therapy resulted in weight loss among obese patients. The intervention, which was provided through in-clinic group visits, telephone calls, or in-clinic individual, visits resulted in positive outcomes in weight management for the patients.

The reviewed studies establish that intensive lifestyle interventions are effective in weight management for obese patients. Patients who were enrolled in different intervention programs lost up to 5 kg during the study duration. In most studies, the duration of the study was 6–12 months.^37,38 Therefore, it is evident that intensive lifestyle interventions are effective. However, research has shown that these interventions are not sustainable in the long term with most participants regaining most of their weight one year after treatment.⁴⁴ Factors such as lack of support, return to an environment that does not encourage adherence to eating and activity habits established during treatment, return to full-time employment, living alone which makes people more vulnerable, and poor mental well-being contribute to this regain.^44,45 There is a need to address these barriers to ensure that the results attained during the intervention are sustainable. For instance, using technology to deliver weight management programs can make them more sustainable, especially for patients who are not able to do in-clinic visits.⁷

Policy Recommendations

As evident from this review, intensive lifestyle interventions are effective in managing weight. As such, they can help to reduce the rising obesity numbers. These interventions can also improve glycemic control and reduce diabetes-related risks such as cardiovascular disease. Findings from this review can inform policies that encourage the adoption of these interventions into care. For instance, urban planning requirements that encourage walkability can encourage more people to participate in physical activity. Research has shown that urban layout has an impact on physical activity, and walkable urban design can increase participation in physical activity and encourage weight loss.⁴⁶ Findings from another study by Creatore et al.⁴⁷ had similar findings. Higher neighborhood walkability in Ontario, Canada, led to a decrease in obesity and overweight prevalence. Higher neighborhood walkability in this case was characterized by urban designs that encouraged pedestrian activity, including walking and cycling.

Having workplace wellness programs can also have a positive impact on the rising obesity cases. Workplace wellness programs that promote an active culture and conducive environment to reduce obesity can help to steer behavior change. Such programs entail implementing policies that can encourage active transportation to and from work to enhance physical activity, provide access to low-cost healthy foods, and flexible work schedules that encourage people to engage more in physical activity.⁴⁸ Research associates these programs with improvements in diet including more intake of fruits and vegetables, body mass index, and waist circumference.⁴⁹

Conclusion

Intensive lifestyle interventions are effective in managing weight and can help individuals with overweight and obesity to lose up to 5–10 kg within a period of 3–6 months. They can also improve other health outcomes such as glycemic control and prevent the risk of diabetes and cardiovascular disease. Because of the benefits that are associated with intensive lifestyle interventions, they present a significant opportunity for individuals living with obesity to manage their weight. When these interventions are combined, an individual is likely to attain the desired weight loss goals. However, to improve their efficacy, it is important to address pressing issues such as accessibility to programs that offer these interventions. Optimizing the intensity and effectiveness of these interventions is also necessary. Using digital platforms to increase accessibility can lead to better outcomes. Such programs can be delivered electronically through different platforms. It is also important to tailor the strategies to individuals depending on their needs and preferences to have better outcomes.

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Cite this article as:
Limiri DM. Intensive Lifestyle Interventions as a Measure to Reduce the Rising Obesity Cases. Premier Journal of Public Health 2025:2;100013

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