According to the cognitive behavior model, thoughts and feelings can be triggers for maladaptive behavior (e.g., excessive eating, sedentary behavior). For example, an individual may have the thought “I’ll never lose the weight” and then stop exercising and monitoring their food intake. The process of cognitive restructuring involves identifying maladaptive thoughts, labeling these thoughts, and replacing them with a more rational thought. For example the thought “I’ll never get the weight off” can be replaced with the thought that “I may have had a difficult week, but I can recover from this slip.” Another strategy would be to challenge the thought, for example by stating “There are times when I’ve lost weight and I’ve already lost 15 lb in this program.” Other techniques include thought-stopping (breaking a negative thinking chain) and distraction (focusing on something else, for example a to-do list).

Emotional change techniques focus on reducing a problematic emotion, such as stress. Individuals can be taught systematic relaxation skills in which they learn how to progressively relax their muscles, one muscle group at a time. Self-soothing is taught as a way to change mood by engaging in non-eating pleasurable events (e.g., taking a bath or a walk). Another strategy is seeking social support from friends or family members. These techniques have been a part of evidenced-based behavioral weight loss treatment packages for years; however they have never been systematically evaluated as components.

Excessive attempts to change thoughts and feelings can lead to maladaptive behavior [4]. Mindfulness and acceptance strategies are an alternative to cognitive and emotional change. Mindfulness techniques teach individuals to notice their thoughts as simply thoughts by training the ability to watch the process of thinking. For example, one might imagine their thoughts as leaves on a stream and envision them floating by. Mindfulness allows individuals to experience a distance between themselves and their thoughts, allowing for more behavioral flexibility (i.e., thoughts no longer need to be responded to/fought with because they are seen as just thoughts).

Acceptance strategies teach individuals how to behave consistently with their values and goals even when unwanted emotions are present. Behavioral repertoires tend to narrow in the presence of difficult emotions. For example, when individuals experience stress, they may stop doing things that matter but take effort, like monitoring calories, exercising, engaging social relationships, and instead engage in a narrow set of behaviors, such as eating and isolation, in an attempt to feel better. The goal of acceptance work is repertoire expansion. The main technique is exposure, though not for the purpose of emotion reduction, but rather to practice sitting with discomfort and also practice making positive behavioral choices in the presence of discomfort. For example, individuals may be taught in session how to notice and experience deprivation by mindfully focusing on different aspects of the emotional experience without pushing it away. Later they are asked to practice this in their natural environment in the presence of tempting foods. An additional acceptance strategy is orienting to the cost of avoidance. For example, if an individual uses food as a way to reduce stress in the short-term, they are encouraged to note the long-term costs of being unwilling to experience stress over the long-term (e.g., weight gain, disease, low energy). Recent studies have shown the potential for adding these techniques to behavioral weight loss interventions [9, 18].

Motivational Interviewing (MI) is a therapeutic approach that focuses on helping individuals work through ambivalence about behavior change. In a MI approach there is generally no direct attempt to confront irrational or maladaptive beliefs, address denial, or to convince or persuade [19]. Instead, the goal is to help clients think about and express their own reasons for and against change and how their current behavior or health status affects their ability to achieve their own values and goals. MI interventionists use reflective listening skills and positive affirmations to help motivate individuals to change their behavior without telling them what to do. Other core MI techniques include allowing the client to interpret information, rolling with resistance, building discrepancy (between statements made by the individual, their behavior, and their core values), and eliciting self-motivational statements [19].

In a standard behavioral approach, interventionists provide education and goals. Individuals may be told about the risks of being overweight and the benefits of weight loss, given specific calorie intake and exercise targets, and instructed to self-monitor their behavior. In contrast, a MI approach would first elicit the person’s understanding and information needs, then provide this in a more neutral manner, followed by allowing space for the individual to express what this means for them, with a question like, “How do you make sense of all this?” MI assumes that individuals are more likely to make behavior changes that they identify and commit to, as opposed to being told what to do. A number of studies have shown that MI can produce improvements in diet and physical activity (e.g., [20, 21]).

The goal of DPP was to determine if an intensive lifestyle intervention could reduce the risk of developing diabetes in individuals with impaired glucose tolerance (IGT). A total of 3,000 overweight/obese individuals with IGT were recruited at 27 clinical sites and randomly assigned to receive the lifestyle intervention, metformin (a medication used to treat diabetes) or placebo. The lifestyle intervention was developed centrally and all counselors, who were typically master’s level nutritionists, received training in the administration of the intervention. The intervention was conducted individually and involved a 16-session core curriculum delivered over 16–24 weeks, followed by ongoing group and individual contact. The goal was to help participants achieve and maintain at least a 7 % weight loss. To achieve this, changes in both diet and activity were stressed. The dietary intervention focused primarily on decreasing fat intake and participants were assigned both a fat gram goal and a calorie intake goal. Physical activity was gradually increased to a goal of 150 min/week of moderate intensity activity such as brisk walking. Participants recorded their intake and exercise daily throughout the core curriculum, and were encouraged to record as needed during maintenance. The lessons used in DPP are available on the DPP website (http://​www.​bsc.​gwu.​edu/​dpp/​lifestyle/​dpp_​part.​html) and focus on the key behavior change strategies, such as stimulus control, changing cognitions, and problem solving.

Participants who received the behavioral intervention achieved an average of 6.9 ± 4.5 % (6.5 ± 4.7 kg) weight loss at the end of the 16 session core curriculum and maintained a weight loss of 4.9 ± 7.4 % (4.5 ± 7.6 kg) at 3.2 year follow-up. Fifty percent of participants achieved the 7 % weight loss goal initially and 38 % at final follow-up [28]. The study was stopped at that time because these weight losses, although modest, were effective in reducing the risk of developing diabetes by 58 % relative to placebo [29]. The lifestyle intervention was also twice as effective as metformin. A follow-up of the DPP, conducted after year 10, showed that although the weight losses in the intensive lifestyle intervention no longer differed significantly from placebo or metformin, the impact on development of diabetes remained highly significant [30].

Based on the success of DPP, another larger trial was launched to examine the long-term health effects of intensive lifestyle intervention in individuals who were overweight or obese and had already developed type 2 diabetes. In this study, called Look AHEAD, 5,145 individuals were recruited at 16 centers and randomly assigned to intensive lifestyle intervention (ILI) or a control group, referred to as Diabetes Support and Education (DSE). The design [31], rationale for the specific components of the lifestyle intervention [32] and the initial and longer term results have been published previously [33–35]. In brief, the lifestyle intervention in Look AHEAD was implemented primarily in groups, with 3 group meetings and 1 individual session during each of the first 6 months, and 2 group meetings and 1 individual session for months 7–12. Subsequently the frequency of contact was decreased, but an effort was made to have contact with each participant at least monthly for years 1–4 and every 3 months in later years.

The intervention was very similar to DPP, with the following modifications [32]. Participants were encouraged to lose 10 % of their body weight and then maintain this. The dietary intervention focused more on reducing caloric intake, since lowering total calories is recognized as more important for weight loss than is the macronutrient composition of the diet. To help participants achieve this caloric reduction, meal plans and meal replacement products were provided to participants for use initially for two meals per day and later for one meal per day. The physical activity goal was increased to 175 min per week based on recent evidence that higher levels of physical activity were important for weight loss maintenance [36]. The lessons used in Look AHEAD are available on the Look AHEAD website (http://​www.​lookaheadtrial.​org/​).

On average, participants in the ILI group lost 8.7 % at 1 year, compared to 0.7 % in DSE. Although the ILI group had a gradual weight regain between years 2 and 4, their weight then plateaued and they maintained weight losses of 6.0 % (vs 3.5 %in DSE) at a median of 9.6 year follow-up (Fig. 13.2). These outcomes were better than seen in DSE at each time point.

The weight losses achieved in Look AHEAD had important health benefits. The ILI group had greater improvements in glycemic control, while requiring less use of insulin, and better improvements in systolic blood pressure with less hypertensive medications. HDL cholesterol improved more in ILI than DSE, but the DSE group had lower levels of LDL-C during the study, due to their greater use of statins. Despite these positive effects on cardiovascular risk factors, the ILI did not reduce the risk of cardiovascular morbidity and mortality. However, it did lead to a large number of other health benefits. Patients in ILI had greater improvements in sleep apnea [37], urinary incontinence [38], and sexual dysfunction [39], reported less depressive symptoms [40] and better physical quality of life [41], and maintained better physical function over time [42].