However, the vast majority of patients on VLCDs regain the weight within 5 years (Miura et al., 1989; Sikand et al., 1988; Wadden et al., 1989; Wing et al., 1991a). VLCDs are quite expensive compared to low-calorie diets; out-of-pocket expenses can exceed $3,500 for the diet itself, medical evaluation and monitoring, individual counseling, and group classes.

Physical Activity

Although most of the do-it-yourself, nonclinical, and clinical programs mention physical activity, it frequently appears to be an afterthought, rather than an integral part of the intervention. Physical activity ranges in intensity from walking to vigorous activities, such as jogging and bicycling. The more vigorous the activity, the more the body's energy stores are utilized. Each individual should develop a realistic goal for increasing activity, starting with a low level that feels comfortable and progressing slowly to higher levels. One key to maintaining an increased level of physical activity is finding the kinds of activities that engage one's interests and can be fit into one's lifestyle and constraints on time. There are few studies of recidivism associated with exercise, though recidivism appears to be high (Dishman, 1988, 1991; Foreyt and Goodrick, 1994). Obesity treatment programs should include a systematically planned and integrated physical activity intervention in order to develop a lifestyle change associated with increased physical activity and thus energy expenditure.

Behavior Modification

Behavior modification is a methodology aimed at helping individuals identify the idiosyncratic problems and barriers interfering with their weight loss and management. Specific behavioral principles are used to solve these problems. No obesity-treatment program can afford to ignore this treatment approach. The principles used in behavior modification typically include self-monitoring, stimulus control, contingency management, stress management, cognitive behavioral strategies, and social support.

Self-monitoring consists of two steps: self-observation and self-recording of those observations. Food and exercise diaries are used to assess the client's eating habits and activity levels. Stimulus control involves identifying the environmental cues associated with unhealthy eating and under-exercising. Modifying the cues often involves strategies such as limiting eating to specific times and places, buying food when not hungry, and laying out exercise clothing to encourage a regular habit of physical activity. Contingency management includes the use of rewards for appropriate

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