Reducing weight in an internal medicine outpatient clinic using a lifestyle medicine approach: A proof of concept


      • Chronic non-communicable diseases are responsible for the majority of deaths.
      • Addressing behavior might represent a strategic change in the health delivery system.
      • Cognitive-behavioral lifestyle strategies can be implemented in outpatient clinics.
      • Lifestyle medicine might represent a strategic asset in the health delivery system.
      • Structured lifestyle medicine interventions might bear relevance to internal medicine.



      Chronic non-communicable diseases represent the major drivers of disease burden, being responsible for the majority of health care cost and deaths. Almost half of premature deaths is due to behaviors amenable to change. Accordingly, addressing behavior might represent a strategic change in the health delivery system. Improving lifestyle requires a specific strategy embedding the active collaboration of individuals with a multilevel team-oriented medical practice. With the present study we sought to assess whether the implementation of cognitive-behavioral strategies, following the principles of lifestyle medicine in an outpatient clinic provides better results in weight reduction as compared to simpler strategies as presently executed in General Practitioners' offices.


      This is an observational study on 173 subjects (age 53.1 ± 11.5), comparing three different groups of preventive practice: a personalized lifestyle medicine, combining cognitive behavioral strategies with patient tailored prescription of exercise and nutrition (Group A); a semi-structured approach with generic counseling (Group B); and an unstructured advice (Group C).


      At the end of the intervention period (17–20 months), group A showed an average weight loss of 5.4 ± 5.1 kg, which was significantly (p < 0.001)more than observed in group B (2.8 ± 5.1 kg) and group C (1.2 ± 4.8 kg). Likewise BMI and waist were progressively more reduced from A to C.


      It is possible to implement preventive cognitive-behavioral lifestyle strategies in outpatient internal medicine clinics. This methodology appears more efficacious in inducing weight reduction after more than a year as compared to usual family medicine approaches.


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        • Go A.S.
        • Mozaffarian D.
        • Roger V.L.
        • Benjamin E.J.
        • Berry J.D.
        • Blaha M.J.
        • et al.
        Heart disease and stroke statistics—2014 update: a report from the American Heart Association.
        Circulation. 2014; 129: e28-e292
        • Spring B.
        • Ockene J.K.
        • Gidding S.S.
        • Mozaffarian D.
        • Moore S.
        • Rosal M.C.
        • et al.
        Better population health through behavior change in adults: a call to action.
        Circulation. 2013; 128: 2169-2176
        • Artinian N.T.
        • Fletcher G.F.
        • Mozaffarian D.
        • Kris-Etherton P.
        • Van H.L.
        • Lichtenstein A.H.
        • et al.
        Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: a scientific statement from the American Heart Association.
        Circulation. 2010; 122: 406-441
        • Milani R.V.
        • Lavie C.J.
        Health care 2020: reengineering health care delivery to combat chronic disease.
        Am. J. Med. 2015; 128: 337-343
        • Perk J.
        • De B.G.
        • Gohlke H.
        • Graham I.
        • Reiner Z.
        • Verschuren W.M.
        • et al.
        European guidelines on cardiovascular disease prevention in clinical practice (version 2012): the fifth joint task force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts).
        Int. J. Behav. Med. 2012; 19: 403-488
        • Sacks F.M.
        • Bray G.A.
        • Carey V.J.
        • Smith S.R.
        • Ryan D.H.
        • Anton S.D.
        • et al.
        Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates.
        N. Engl. J. Med. 2009; 360: 859-873
        • Pagoto S.L.
        • Appelhans B.M.
        A call for an end to the diet debates.
        JAMA. 2013; 310: 687-688
        • American College of Lifestyle Medicine
        The American College of Lifestyle Medicine Standards.
        in: Rooke Jennifer Gobble John Ballard Tasha Oglesby Willy Guthrie George Howard Corey 2015 (
        • Philips J.S.
        ACSM's exercise is medicine.
        Lippincott Williams & Wilkins, 2009
        • Pearson T.A.
        • Palaniappan L.P.
        • Artinian N.T.
        • Carnethon M.R.
        • Criqui M.H.
        • Daniels S.R.
        • et al.
        American Heart Association Guide for Improving Cardiovascular Health at the Community Level, 2013 update: a scientific statement for public health practitioners, healthcare providers, and health policy makers.
        Circulation. 2013; 127: 1730-1753
        • Roth G.A.
        • Forouzanfar M.H.
        • Moran A.E.
        • Barber R.
        • Nguyen G.
        • Feigin V.L.
        • et al.
        Demographic and epidemiologic drivers of global cardiovascular mortality.
        N. Engl. J. Med. 2015; 372: 1333-1341
        • van Dam R.M.
        • Li T.
        • Spiegelman D.
        • Franco O.H.
        • Hu F.B.
        Combined impact of lifestyle factors on mortality: prospective cohort study in US women.
        BMJ. 2008; 337: a1440
        • Capewell S.
        • Lloyd-Jones D.M.
        Optimal cardiovascular prevention strategies for the 21st century.
        JAMA. 2010; 304: 2057-2058
        • Carnethon M.
        • Whitsel L.P.
        • Franklin B.A.
        • Kris-Etherton P.
        • Milani R.
        • Pratt C.A.
        • Wagner G.R.
        Worksite wellness programs for cardiovascular disease prevention: a policy statement from the American Heart Association.
        Circulation. 2009; 120: 1725-1741
        • Lucini D.
        • Solaro N.
        • Lesma A.
        • Gillet V.B.
        • Pagani M.
        Health promotion in the workplace: assessing stress and lifestyle with an intranet tool.
        J. Med. Internet Res. 2011; 13: e88
        • Lucini D.
        • Zanuso S.
        • Blair S.
        • Pagani M.
        A simple healthy lifestyle index as a proxy of wellness: a proof of concept.
        Acta Diabetol. 2015; 52: 81-89
        • Lucini D.
        • Riva S.
        • Pizzinelli P.
        • Pagani M.
        Stress management at the worksite: reversal of symptoms profile and cardiovascular dysregulation.
        Hypertension. 2007; 49: 291-297
        • Lucini D.
        • Zanuso S.
        • Solaro N.
        • Vigo C.
        • Malacarne M.
        • Pagani M.
        Reducing the risk of metabolic syndrome at the worksite: preliminary experience with an ecological approach.
        Acta Diabetol. 2015;
        • Murphy A.W.
        • Cupples M.E.
        • Smith S.M.
        • Byrne M.
        • Byrne M.C.
        • Newell J.
        Effect of tailored practice and patient care plans on secondary prevention of heart disease in general practice: cluster randomised controlled trial.
        BMJ. 2009; 339: b4220
        • Lianov L.
        • Johnson M.
        Physician competencies for prescribing lifestyle medicine.
        JAMA. 2010; 304: 202-203
        • Graham I.
        • Atar D.
        • Borch-Johnsen K.
        • Boysen G.
        • Burell G.
        • Cifkova R.
        • et al.
        European practice guidelines on prevention of cardiovascular diseases: executive summary.
        G. Ital. Cardiol. (Rome). 2008; 9: 11-59
        • Rollnick S.
        • Butler C.C.
        • Kinnersley P.
        • Gregory J.
        • Mash B.
        Motivational interviewing.
        BMJ. 2010; 340: c1900
        • Lantz H.
        • Peltonen M.
        • Agren L.
        • Torgerson J.S.
        A dietary and behavioural programme for the treatment of obesity. A 4-year clinical trial and a long-term posttreatment follow-up.
        J. Intern. Med. 2003; 254: 272-279
        • Lin J.S.
        • O'Connor E.
        • Evans C.V.
        • Senger C.A.
        • Rowland M.G.
        • Groom H.C.
        Behavioral counseling to promote a healthy lifestyle in persons with cardiovascular risk factors.
        Ann. Intern. Med. 2014; 161: 568-578
      1. J.S. Lin, E.A. O'Connor, C.V. Evans, C.A. Senger, M.G. Rowland, H.C. Groom, Behavioral counseling to promote a healthy lifestyle in persons with cardiovascular risk factors: an updated systematic evidence review for the U.S. Preventive Services Task Force. AHRQ Publication No. 13-05179-EF-1 2014; Evidence Synthesis, No. 113.

        • ACSM's
        Guidelines for exercise testing and prescription.
        9th ed. Lippincot Williams & Wilkins, 2013
        • American Diabetes Association
        Standards of Medical Care in Diabetes—2015.
        Diabetes Care. 2015; 38: S1-S94
        • Estruch R.
        • Ros E.
        • Salas-Salvado J.
        • Covas M.I.
        • Corella D.
        • Aros F.
        • et al.
        Primary prevention of cardiovascular disease with a Mediterranean diet.
        N. Engl. J. Med. 2013; 368: 1279-1290
        • Kushi L.H.
        • Byers T.
        • Doyle C.
        • Bandera E.V.
        • McCullough M.
        • McTiernan A.
        • et al.
        American Cancer Society Guidelines on Nutrition and Physical Activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity.
        CA Cancer J. Clin. 2006; 56: 254-281
        • Kraus W.E.
        • Bittner V.
        • Appel L.
        • Blair S.N.
        • Church T.
        • Despres J.P.
        • et al.
        The national physical activity plan: a call to action from the American Heart Association: a science advisory from the American Heart Association.
        Circulation. 2015; 131: 1932-1940
        • Eakin E.G.
        • Lawler S.P.
        • Vandelanotte C.
        • Owen N.
        Telephone interventions for physical activity and dietary behavior change: a systematic review.
        Am. J. Prev. Med. 2007; 32: 419-434
        • Koelewijn-van Loon M.S.
        • van der Weijden T.
        • van S.B.
        • Ronda G.
        • Winkens B.
        • Severens J.L.
        • et al.
        Involving patients in cardiovascular risk management with nurse-led clinics: a cluster randomized controlled trial.
        CMAJ. 2009; 181: E267-E274
        • Orrow G.
        • Kinmonth A.L.
        • Sanderson S.
        • Sutton S.
        Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials.
        BMJ. 2012; 344: e1389
        • Prochaska J.J.
        • Prochaska J.O.
        A review of multiple health behavior change interventions for primary prevention.
        Am. J. Lifestyle Med. 2011; 5
        • Gulliksson M.
        • Burell G.
        • Vessby B.
        • Lundin L.
        • Toss H.
        • Svardsudd K.
        Randomized controlled trial of cognitive behavioral therapy vs standard treatment to prevent recurrent cardiovascular events in patients with coronary heart disease: Secondary Prevention in Uppsala Primary Health Care project (SUPRIM).
        Arch. Intern. Med. 2011; 171: 134-140
        • Naci H.
        • Ioannidis J.P.
        Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study.
        BMJ. 2013; 347: f5577
        • Eckel R.H.
        Role of glycemic index in the context of an overall heart-healthy diet.
        JAMA. 2014; 312: 2508-2509
        • Sealy Y.M.
        • Zarcadoolas C.
        • Dresser M.
        • Wedemeyer L.
        • Short L.
        • Silver L.
        Using public health detailing and a family-centered ecological approach to promote patient–provider–parent action for reducing childhood obesity.
        Child. Obes. 2012; 8: 132-146
        • Wadden T.A.
        • Volger S.
        • Sarwer D.B.
        • Vetter M.L.
        • Tsai A.G.
        • Berkowitz R.I.
        • et al.
        A two-year randomized trial of obesity treatment in primary care practice.
        N. Engl. J. Med. 2011; 365: 1969-1979
      2. The soft science of medicine.
        Lancet. 2004; 363: 1247
        • Kaplan R.M.
        • Satterfield J.M.
        • Kington R.S.
        Building a better physician—the case for the new MCAT.
        N. Engl. J. Med. 2012; 366: 1265-1268
      3. Academy of Medical Royal Colleges. Exercise: the miracle cure and the role of the doctor in promoting it.
        • Frank E.
        STUDENTJAMA. Physician health and patient care.
        JAMA. 2004; 291: 637
        • Umpierre D.
        • Ribeiro P.A.
        • Kramer C.K.
        • Leitao C.B.
        • Zucatti A.T.
        • Azevedo M.J.
        • et al.
        Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: a systematic review and meta-analysis.
        JAMA. 2011; 305: 1790-1799
        • Lucini D.
        • Pagani M.
        Exercise: should it matter to internal medicine?.
        Eur. J. Intern. Med. 2011; 22: 363-370
        • John H.
        • Hale E.D.
        • Bennett P.
        • Treharne G.J.
        • Carroll D.
        • Kitas G.D.
        Translating patient education theory into practice: developing material to address the cardiovascular education needs of people with rheumatoid arthritis.
        Patient Educ. Couns. 2011; 84: 123-127
        • Critchley C.R.
        • Hardie E.A.
        • Moore S.M.
        Examining the psychological pathways to behavior change in a group-based lifestyle program to prevent type 2 diabetes.
        Diabetes Care. 2012; 35: 699-705
        • David Markland
        • Ryan Richard M.
        • Jayne Tobin Vanessa
        • Stephen Rollnick
        Motivational interviewing and self-determination theory.
        J. Soc. Clin. Psychol. 2005; 24: 811-831
        • Montathar Faraon
        • Georg Stenberg
        • Mauri Kaipainen
        Political campaigning 2.0: the influence of online news and social networking sites on attitudes and behavior.
        eJournal eDemocracy Open Gov. 2014; 6: 231-247