Although the essential role of physical activity in the treatment of obesity is widely recognized, the simple prescription of exercise by health care providers does not seem to have any relevant effect on long-term behavior of overweight and obese individuals [8,9]. In fact, the increase of activity levels requires a complex modification of lifestyle, which cannot be achieved through a simple prescription. Two different strategies can be implemented (and have been tested in clinical trials): supervised programs of aerobic training, or behavioral techniques either to increase lifestyle activity or to promote structured unsupervised exercise programs.
The approach through supervised programs has been used in several trials with good short-term results. It can be implemented either in the format of group programs in dedicated facilities, or as an individual program in a home-based fashion. In either case, it is an expensive approach: general practices and specialist clinics are usually not equipped with facilities for group-supervised physical exercise; on the other hand, any individual, home-based program is remarkably time-consuming for exercise supervisors. In fact, supervised programs seem to be more appropriate for randomized trials than for routine clinical practice. Furthermore, it has been observed that, once that a supervised program has been terminated, its effects on levels of physical activity of participants tend to disappear with time .
Behavior therapy for obesity includes a variety of interventions specifically aimed at long-term modification of eating and exercise habits, which is obtained through a direct involvement of the patient in the management of diet and physical activity . Although behavioral treatments can be very different one from another, typical features include:
1. Education and planning: the patient is provided with information about the benefits of exercise, and a training program is planned together by the patient and his/her health provider;
2. Self-monitoring: the patient is invited to record type, intensity, and duration of exercise, in order to monitor compliance to the planned exercise program. If impediments arise, these can be discussed with therapists. Self-monitoring sheets can also be used to monitor some positive effects of exercise, i.e., performance, for positive reinforcement (see below).
3. Positive reinforcement: it is essential that the patient receive some positive feedback from his/her training program, such as pleasure during exercise sessions, improvement of performance (in specific tasks or in activities of daily living), modifications of metabolic parameters, etc.
Behavioral techniques for increase of activity in obese patients can be applied in individual or group sessions, or with a combination of both. Group interventions, when feasible, seem to be more effective than the individual approach . Most authors agree that, in order to obtain satisfactory long-term results, behavioral interventions should be completed by some kind of follow-up contact, even through telephone calls , internet or email .
In most instances, behavioral interventions on physical activity in obese or overweight patients have been applied in association with supervised training, within more complex programs which included also dietary interventions. The two largest trials of this kind described so far, the Finnish Diabetes Prevention Study  and the Diabetes Prevention Program , both increased significantly activity levels in participants after a follow-up of 3-4 years [15,16].Although the results of these two trials are very relevant, it should be considered that the patients enrolled were aware of the fact that they were at risk for diabetes, and that physical exercise was effective in the prevention of that disease; the long-term efficacy of this approach in the management of obesity uncomplicated by glucose intolerance needs further investigation. In obese schoolchildren, a program including both structured supervised physical exercise and behavioral techniques to reduce sedentary activities during leisure time, as well as appropriate dietary advice, produced encouraging results at 1 year, although a longer follow-up is needed to confirm the efficacy of this approach .
A relatively inexpensive and simple behavioral approach to the increase of physical activity, which was not associated with supervised training, nor with specific dietary intervention, was shown to be effective in enhancing activity levels, and ameliorating a number of metabolic parameters, in overweight type 2 diabetic patients . Although obtained in a population which is in many ways different from that of obese nondiabetic individuals, this result is encouraging for simple, nonprescriptive approaches to exercise in the treatment of obesity.
In summary, although the central role of physical activity in the treatment of obesity is widely recognized, the simple prescription of exercise is usually ineffective. Individual or group behavioral programs designed to enhance activity levels in the long term are a much more promising approach.
A simple behavioral program for the increase of exercise in obese patients, which can be easily applied in clinical practice, should be introduced by proper information on the benefits of physical activity, in order to enhance motivation. An initial program of physical activity (which can be represented by lifestyle activities or by more structured exercise depending on the characteristics of the individual patient) should be agreed upon by the patient and the therapist. The implementation of this program can be assessed by regular self-monitoring (i.e., an exercise diary compiled by the patient). Some parameters of performance should be included in monitoring, to enhance motivation. In follow-up visits, the therapist can discuss with the patient impediments to the implementation of the program and determine new exercise goals, increasing gradually the levels of activity. In this process, the therapist should focus the attention of the patient on detected improvements in metabolic parameters determined by physical activity, and on the pleasant aspects of exercise. Physical activity should be perceived by the patient as a pleasure, and not as a punishment. The implementation of this kind of intervention requires some behavioral skills on the side of the health providers. Although a psychologist or a psychotherapist is not usually needed within the health care team, all professionals (physicians, dieticians, physical therapists and/or motor sciences specialists) should receive some behavioral training.
The use of structured supervised exercise sessions in combination with behavioral programs is likely to produce a relevant improvement in weight loss, at least in the short term. The main obstacle to this intervention is represented by the need for specific facilities within (or nearby) obesity clin-
ics, which require remarkable financial resources. Considering the heavy toll of obesity on the health status of the population of developed countries, and the resulting impact on public expenditure for the care of overweight-associated diseases, expenses for training facilities and specialized personnel for the implementation of supervised exercise programs for obesity should represent a good investment in the long term.
Another key point for the success of obesity programs is the quality of follow-up. Although behavioral interventions have been shown to be more effective than traditional dietary and exercise prescription in the medium term , their effects seem to disappear in the longer term. Regular follow-up session, mainly devoted to the increase of motivation, can be crucial for long-term success . Such sessions can be implemented either in the format of individual visits, telephone interviews, or internet and/or e-mail contacts [11,12]. The use of new communication technologies, whenever possible, could be very advantageous for the containment of costs.
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