Subcommittee of Nutritionists: Robert Nicolosi, Ph.D., Chairman; Diane Becker, Sc.D., M.P.H.; Patricia Elmer, Ph.D., R.D.; John Foreyt, Ph.D.; Wahida Karmally, M.S., R.D.; Katherine McManus, M.S., R.D.; Lynne W. Scott, M.A., R.D.; Marilyn F. Zukel, M.S., RD; for the AHA Nutrition Committee

Weight loss to improve cardiovascular health is a high priority of the American Heart Association because approximately 34 percent of the population is overweight. There is a great deal of public, commercial and medical interest in promoting long-term weight loss programs. The AHA Nutrition Committee has been asked to provide general guidelines for weight management programs for healthy adults. Unfortunately, data supporting the long-term effectiveness of such programs are lacking, and the efficacy of some elements of weight loss programs is unknown. However, some general, common-sense guidelines can serve as a basis for recommendations to the general public. Until further research can provide more definitive information, the following recommendations, developed by the AHA Subcommittee of Nutritionists and critically reviewed by the AHA Nutrition Committee, are a reasonable basis for evaluating weight management programs. Some of the information was adapted from "Toward Safe Weight Loss: Recommendations for Adult Weight Loss Programs in Michigan" by the Michigan Health Council.

-Nutrition Committee, American Heart Association

The purpose of this report is to establish guidelines for the development and evaluation of nonpharmacological and nonsurgical weight management programs. These guidelines were prepared because of the importance of weight control for achieving and maintaining better health and particularly for preventing and controlling cardiovascular disease.

These guidelines are developed for use by healthy adults. They are not intended for:

• People who are severely or morbidly obese(ie, who are 100 pounds or more above their ideal body weight)
• Children younger than 18 years
• Adults with preexisting illness or metabolic disorders (such as diabetes) who should be treated by a qualified health care team

The AHA recognizes that information on the benefits of weight loss in the elderly (people aged 75 years and older) is clearly lacking and consequently recommends that elderly people discuss their plans with their physicians before beginning a weight loss program. They should be encouraged to adopt a healthy lifestyle that includes a low-fat diet and regular physical activity.

These guidelines focus on the health benefits of weight loss associated with a healthy lifestyle that should lead to improved cardiovascular health (eg, a reduction in serum levels of total cholesterol, low density lipoprotein cholesterol, and blood pressure and an increase in high density lipoprotein cholesterol). The guidelines also emphasize the importance of weight management programs in which participants achieve and maintain realistic weight loss goals for a lifetime because the maintenance of even small weight losses may be associated with improvements in cardiovascular risk factors. In addition, the achievement and maintenance of realistic weight loss goals are critical to effective weight management programs. Some studies have suggested increased morbidity and mortality as a result of weight cycling; others have not. This issue will not be resolved without further study. Weight management programs are less likely to be effective if they are not adapted to the individual characteristics of each participant.

The question of who should lose weight has frequently been asked of health care professionals; however, comprehensive guidelines for the general public are not available. Clearly, people who might benefit medically from weight loss should be targeted because the reduction of risk factors for heart disease, hypertension, and diabetes improves quality of life as well as reduces future health care costs. People with a history of weight cycling should also be encouraged to enroll in professionally supervised weight management programs that are based on realistic weight loss goals. The use of weight management programs solely to achieve aesthetic changes should be discouraged because of the unnecessary exposure to the risks of weight cycling.

People who are within 20% of their ideal body weight might be more appropriately encouraged to increase their physical activity and reduce their dietary fat intake to levels associated with good health rather than to lose weight, because such improvements should result in a lower body fat level and favorable changes in blood lipids and blood pressure. Those who are more than 20% above their ideal body weight should be considered potential candidates for effective weight management programs, especially if they are at risk for coronary heart disease, hypertension, or diabetes. People with abdominal obesity should be screened for unfavorable lipid profiles, high blood pressure, or abnormal glucose tolerance because abdominal obesity has been associated with increased risk for these problems. More research is needed to develop methods of identifying abdominal obesity.

Although the development of obesity has a genetic component, the mechanism is unknown, and for most people the imbalance between energy intake and energy expenditure is the key. Weight gain is usually due to an excess of energy intake, a lack of energy expenditure due to low levels of leisure-time physical activity, or both. A successful weight loss program therefore must (in addition to being nutritionally sound) be based on a reduction of energy intake, including reduced intake of total fat and saturated fat, and an increase in energy expenditure through physical activity.

For weight loss, the intensity of physical activity is not nearly as important as the amount and duration. For example, there is only a small difference between the amount of energy expended by briskly walking 10 blocks and by running 10 blocks. As people lose weight their energy needs decrease because of a decline in resting metabolic rate, and weight loss will be slowed (or there may even be some weight gain) if they continue to consume the same amount of energy in food without increasing energy expenditure. It is therefore extremely important to gradually increase physical activity to maintain weight control.

The proposed dietary changes, the most important of which is reduction of total fat and saturated fat intake, should be both pleasant and acceptable, and the increased physical activity should be enjoyable, practical, and safe. People who have difficulty maintaining a normal weight should be evaluated by a physician, especially if they are very overweight or have been unsuccessful in weight loss programs. Most people lose weight and maintain weight loss on their own by reducing their energy intake, frequently that from fat (because fat has more energy per gram than protein or carbohydrate), and by increasing their energy expenditure through physical activity. However, some people may prefer an organized weight loss program. Such programs should conform to the principles of the AHA guidelines for weight reduction by reducing intake of total fat and saturated fat. The program should be based on a balanced diet (ie, a nutrient intake sufficient to prevent deficiencies of vitamins and minerals), and provide a safe and pleasant program of physical activity.

The essential components of a safe and effective weight management program are:

• Participant/patient information (informed consent)
• Screening of all persons beginning a weight management program by use of an appropriate medical history form to identify people who require a physician's supervision
• Guidelines for who needs to be evaluated by a physician before beginning a weight management program (Appendix A)
• Staffing by individuals qualified by education, training, and experience to provide these services
• Identification of reasonable weight loss goals (is weight loss needed to reduce risk for cardiovascular disease [eg, improved lipid profiles, blood pressure, or diabetes] or to improve general health [eg, improved pulmonary, cardiac, and musculoskeletal fitness]?)
• Individualized nutritional, exercise, and behavioral components
• A maintenance program for at least 2 years
• Evaluation of the long-term effectiveness and safety of the program by review of weight loss and health status of all participants after completion of the program and at 1, 2, and 5 years after program completion (ie, data on the number of participants who begin the program, the number who complete the program, and participants' weight and health status [blood pressure, blood lipids, and any health complications] should be reported, stratified by gender, at these intervals; information on the number of participants who restart the program should be reported separately)
• Participants in most weight loss programs meet once a week during the initial phase, which generally lasts from 12 to 24 weeks. Because participants should be followed up for a full year, 12 contacts during the first year appears to be a reasonable minimum number of contacts.

Before beginning a weight management program, each participant should sign a consent form witnessed by a competent adult. The consent form should describe:

• The number and format of contacts between the participant and the program supervisor
• A reasonable weight goal
• Estimated time frames for reaching the weight goal
• Health and psychological benefits that can be achieved through weight loss
• Physical and psychological risks associated with weight loss
• The level of training and credentials of the people providing weight management supervision
• What is necessary to comply with program contractual conditions
• The actual cost of treatment, including all products, services, supplements, and laboratory tests
• The need for medical monitoring in specific cases

In addition to the items included in a customary consent document, each participant should be informed about:

• Current data on the likelihood that weight loss will be maintained (a high percentage of individuals who lose weight have regained it in 5 years)
• Potential physical and psychological risks associated with regaining the lost weight and with weight cycling
• Scientifically valid data to substantiate any claim about the success rate of the program

If there are no data to demonstrate that program participants maintain their weight losses for 5 years or more, there is no scientific evidence of long-term results of the program. Case histories of program successes are not sufficient and should not be presented as descriptive of the program's overall success rate.

All persons providing weight management services should be qualified by education, training, and experience to provide these services. In addition to basic nutrition education and training in individualizing counseling and eating plans, all providers should have documentation of continuing education on a yearly basis in the area of weight management.

Registered dietitians (RDs), dietitians, or nutritionists licensed or certified by the state (eg, LDs or CNs) should be responsible for the nutrition component of the weight management program. RDs are registered by the Commission on Dietetic Registration, the credentialing agency for the American Dietetic Association. Nutrition intervention specialists not in the categories above should be trained by these professionals and receive continuing education on a regular basis. An RD (or LD/CN) should be available for consultation with participants.

Physicians who supervise weight management programs must be licensed by the state in which they work and should know how to access a dietitian referral network. They should also be knowledgeable about medical problems associated with obesity, weight loss, and weight regain, and should, ideally, be experienced in the management of these medical problems.

The exercise component should be developed or approved by trained health professionals who are certified by the American College of Sports Medicine (ACSM) or have an equivalent level of training. The ACSM certifies Exercise Leaders, who have the equivalent of an associate degree in an allied health field; Health and Fitness Instructors, who have a baccalaureate degree related to exercise; and Exercise Specialists, who hold a master's degree. People with training in exercise physiology and clinical experience in weight management should also provide the exercise component of weight management. Participants at high risk may need physician referral or monitoring as part of the exercise prescription.

Behavior modification principles should be developed by a behavioral scientist who has the education and experience to conduct training sessions. Behavioral scientists include persons with masters' or doctoral degrees in psychology or health education who have had training in behavioral sciences. They must also have completed curricular components in behavior modification techniques or psychology.

Lay leaders in the program should receive appropriate training by RDs, exercise leaders, and behavioral scientists as indicated above. They should have ready access to health professionals for consultation, participate in regular, documented continuing education, and be monitored to ensure that approved programs are being conducted as intended. Special attention should be given to training lay leaders (and all people conducting the program) in cultural diversity.

The weight goal for the participant should be reasonable and based on personal, cultural and family weight history, not exclusively on height and weight charts or body mass index (BMI). Setting unrealistically low weight goals virtually ensures that rapid weight loss will be followed by equally rapid regain. There is no scientifically validated method for defining optimum body weight for a given individual.

The most important factor in determining the weight goal is the amount of weight loss needed so that weight no longer impedes normal functions, health, employment, or life activities. A realistic weight goal depends largely on past weight. For example, a person with a strong family history of obesity and a lifelong personal history of overweight should not be promised a final weight in the normal range. Although the participant should help set the weight goal, it is appropriate to dissuade him or her from striving for an unrealistically low weight goal. Particular care should be taken in establishing weight loss goals for people who may be at risk for eating disorders such as bulimia or anorexia nervosa.

Step-wise weight goals, whereby the participant agrees to work toward a modest weight reduction, can be adopted. If the initial weight loss is maintained for some agreed-upon period, further weight reduction can be attempted.

The advertised and actual rate of weight loss, after the first 3 to 4 weeks of treatment, should not exceed an average of 1 pound per week. Slow, gradual weight loss rather than rapid weight loss is recommended because it minimizes the risk of metabolic disturbances and is less likely to induce a state of extreme energy deprivation, which can result in reduced compliance. Rapid weight loss is associated with the most rapid rate of subsequent weight regain. A person whose average rate of weight loss greatly exceeds 1 lb/wk may be at increased health risk and may require closer and more frequent medical supervision. Non-medically supervised programs that claim rates of weight loss greater than an average of 1 lb/wk should be avoided.

The nutritional recommendations for each participant's treatment should include a personal food plan that takes into account current eating habits, lifestyle, ethnicity and culture, energy needs, any diet prescription related to medical treatment, and potential nutrient-drug interactions. There should also be provisions for documenting adherence to the food plan and enhancing motivation for dietary compliance (which may include identifying and addressing barriers to, and providing reinforcement for, compliance). Specific goals related to food intake, behavioral changes, and physical activity need to be established and discussed at each follow-up visit.

Daily Energy Intake. The energy intake prescribed should be adjusted so that an individual can achieve but not exceed the safe rate of weight loss. When energy intake is calculated, estimated daily energy expenditure should be considered. Energy intake should be reevaluated periodically to ensure that the rate of weight loss does not greatly exceed the 1 lb/wk average. Health risks from weight loss increase as energy intake decreases. Medical involvement should increase at lower energy levels. A minimum of 5020 kJ (1200 kcal) per day for women and 6300 kJ (1500 kcal) per day for men should be provided.

If weight loss cannot be achieved at these minimal levels, even with the dietary and exercise compliance, the diet prescription and level of energy intake should be modified and monitored. Accurate assessment of both dietary and exercise compliance over several weeks should be emphasized.

Intake of 5020 kJ or less per day requires special attention to meeting the recommended daily allowances for all nutrients. See Appendix B for information on very?low-calorie diet regimens and formula products.

Diet Composition. Dietary prescriptions should be consistent with the AHA's dietary guidelines (Appendix C).

• Protein. Protein should provide about 15% of energy and be of high biological value. The protein needs of participants with renal disease, diabetes, or other metabolic disorders must be determined in consultation with a physician.
• Fat. Less than 30% of energy should be from fat; less than 10% of energy should be from saturated fatty acids, up to 10% should be from polyunsaturated fatty acids, and the remainder should be from monounsaturated fatty acids.
• Carbohydrate. The diet should provide 55% or more of energy as carbohydrate, the majority being complex carbohydrates. Diets rich in complex carbohydrate and fiber are consistent with health promotion and disease prevention in healthy people.
• Fluids. At least 1.5 to 2.0 quarts of fluid, preferably water, should be consumed daily, and more is needed when vigorous exercise is performed. Beverages that provide large amounts of energy as simple sugars or fat should be avoided.

Nutritional Adequacy. Food plans should be designed so that participants are likely to select foods that meet all the RDAs except that for energy. The diet should include foods from all the food groups, particularly fruits, vegetables, and whole grains. A moderate intake of lean meats, poultry, fish, and low-fat dairy products can be part of a healthful diet.

Meal plans supplying 5020 kJ or less may not provide recommended levels of vitamins and minerals. Therefore, a daily vitamin and mineral supplement may be taken so that the RDAs are met. The use of megadoses of vitamins and minerals is not recommended.

Nutrition Education. Nutrition education should be incorporated into the weight management program to encourage permanent healthful eating patterns consistent with the AHA dietary guidelines for healthy American adults (Appendix C). Participants should avoid crash dieting and instead gradually adopt more healthful eating habits that can be maintained for a lifetime. Selection and preparation of low-fat foods and selection of low-fat alternatives while dining out should be emphasized.

Participants should be involved in meal planning and food decisions throughout the weight loss period to encourage the practice of healthful food selection skills. They should also learn how energy needs are affected by physical activity and changes in weight. The range of food options during the weight loss period should be as broad as possible and ethnically and culturally acceptable to each person. Education about including familiar, highly desired foods in the food plan can help reduce feelings of extreme deprivation, improving adherence.

Exercise should be considered one of the highest priorities of a weight management program. The weight management program should include an exercise component that is safe and appropriate for each participant.

Before exercise recommendations are made, each person should be screened for conditions in which exercise could be contraindicated. Participants should be made aware of both normal and abnormal physiological responses to exercise. They should work toward performing at least 30 to 60 minutes of physical activity five to seven times per week. In addition, increasing leisure-time activity levels should be encouraged.

Incorporation of exercise into a person's permanent lifestyle increases the likelihood of long-term success in weight loss. Regular exercise also helps to increase energy expenditure, maintain lean body mass, improve functional capacity, reduce cardiovascular risk, and promote a sense of personal well-being. The activity can be any exercise that uses large muscle groups and is rhythmic. It should be consistent with individual interests and an activity that can become a permanent part of the lifestyle. Low-impact aerobic activities such as walking and bicycling are desirable because they are less likely to cause orthopedic injury and they carry a smaller risk of cardiovascular complications. They are also more likely than more intense activities to be continued. Low-intensity activity for longer periods can produce weight loss benefits similar to those of high-intensity activity done for shorter periods. All participants should be encouraged to be more physically active and to identify opportunities for increased activity that can be incorporated into their lifestyle. Examples might include 10- to 15-minute walks after meals or during coffee breaks, or using stairs rather than elevators.

The exercise should begin at a comfortable pace and be increased gradually. Participants at any level of fitness should start at a slow pace for a short time, then increase the intensity, duration, and frequency of exercise until it can be comfortably continued for the desired time (30 to 60 minutes). Each level of intensity and duration should be maintained for at least 1 to 2 weeks. Progressing too rapidly will result in muscle soreness, fatigue, increased cardiac risk, and decreased motivation. Each exercise period should include warm-up and cool-down periods, during which exercise is done at a slower pace. Weight management participants can achieve better fitness by performing the same activities they chose for weight loss but at increased intensities. Participants need to be aware of the need to monitor their increased activity levels to maintain the benefits of an active lifestyle.

Each participant should have an individualized exercise plan. Specific exercise recommendations should include:

• Indicating the type of exercise to be done
• Specifying frequency, duration, and intensity of the exercise
• Gradually increasing the frequency, duration, and intensity of the exercise
• Ensuring that the participant can recognize and deal with abnormal physical responses to exercise
• Documenting exercise
• Enhancing adherence to the exercise goals, which may include identifying barriers to exercise and identifying reinforcers for compliance with goals

A review of the lifestyle and occupation should be conducted to identify strategies for increasing the level of activity throughout the day.

Water intake during exercise should be ample to prevent dehydration and overheating. Very overweight people may be particularly vulnerable to heat exhaustion. Participants may drink water before, during, and after exercise and should pay close attention to thirst so that dehydration does not occur. It should be noted that the thirst mechanism is not adequate to prevent dehydration in many elderly people or in people engaging in extremely heavy exercise, particularly in hot weather.

People with conditions such as diabetes, hypoglycemia, peripheral vascular disease, and blood volume changes should be medically supervised. These people need to be aware of warning symptoms of their disease that may surface during physical activity. They also need guidance in learning precautions they can take to avoid or control these problems, and they need to learn whether there are particular hazards associated with their underlying condition. For example, people with diabetes and vascular disease need to be aware of the importance of excellent foot care when they begin an exercise program.

Behavioral strategies suitable for each person should be identified by working with participants to define the behaviors that contribute to their being overweight, to identify the causes of these behaviors, and to select strategies that they feel comfortable using to change their behavior. These strategies may include self-monitoring, stimulus control, rewards, stress management, or problem-solving, cognitive-behavioral, or relapse prevention approaches. Support groups can be especially helpful.

Weight management programs should include a maintenance component for participants who reach their weight goals. The most important factor associated with the ability to maintain weight loss may be acceptance of personal responsibility for lifestyle changes. Several factors may be associated with long-term weight maintenance: incorporation of exercise into the permanent lifestyle, self-monitoring techniques after weight loss has been achieved, lapse/relapse prevention strategies, and social support for individual lifestyle changes.

Data can be collected most effectively in standardized face-to-face interviews with participants at the time of program initiation and follow-up. The data, compiled in aggregate form by gender, should include:

1. Definitions for the length of the weight loss and weight maintenance phases of the program

    

2. Percentage of all participants who completed the program

    

3. Percentage of those completing the initial weight loss phase of the program who achieve various degrees of weight loss and weight gain, including the mean and range of weight loss values for the program

    

4. Percentage of participants who began and completed the weight maintenance phase of the structured program (self-reported data are not acceptable)

    

5. Percentage of participants who maintain weight loss at 1, 2, and 5 years

    

6. Percentage of participants with improved cardiovascular disease risk factor status at 1, 2, and 5 years

    

7. Percentage of participants who experience adverse medical or psychological effects and the nature and severity of these effects

    

8. Reasons for dropping out

    

9. Percentage of participants who meet their goals

Additional information about a program's characteristics should include:

1. Relative emphasis on the diet, exercise, and behavior components

    

2. Frequency, duration, and kinds of contacts

    

3. Nature and duration of the structured maintenance phase

    

4. Flexibility of food choices and suitability of food types being promoted

The success of a program is ultimately reflected by long-term maintenance of weight loss and healthy lifestyle habits. Achievement of a desirable body weight is not realistic for all participants, and desirable body weights do not always reflect ethnic diversity and gender differences; therefore, maintaining a reasonable weight loss, rather than achieving an ideal body weight, should be equated with success. The concept of reasonable weight loss is important, because some individuals will not be able to achieve an "ideal" weight despite maintaining an optimal diet and being physically active. Undue pressure to achieve an unattainable weight can be counterproductive and undermine long-term maintenance of small to moderate weight loss.

Data should be collected at baseline to determine long- and short-term complications of weight loss. Persons who experience complications must be referred to their physicians. Regular and documented assessment should include periodic measurement of body weight to ensure an average weight loss of no more than 1 lb/wk. (In the first few weeks of a program, slightly more weight may be lost.) More rapid weight loss is undesirable. Persons who fall below recommended body weight ranges or who exceed the recommended weight loss should be referred to their physicians for evaluation. Negative sequelae of excessive weight loss may be determined through a brief, general health inquiry at each visit. Any changes in health, mood, or physical or mental performance or the presence of symptoms should be noted, as should headaches, fatigue, emotional distress, loss of lean muscle mass or muscle aching, palpitations, postprandial symptoms, changes in menstrual cycle, hair loss, abdominal discomfort, or edema, among other symptoms. These data should be maintained in aggregate form. Data on the number and nature of referrals to physicians should be recorded.

It is important that aggregate data from participants in weight management programs be made available to the public to ensure the programs' safety and effectiveness. Data should be recorded on average weight loss, the range of weight loss, and all negative health consequences that require physician referral.

Assessment of Health Risk Status

The primary objective of referral for initial assessment and continued monitoring of people with disease or cardiovascular risk factors is to ensure their safety. Before beginning a weight loss regimen, people who are severely obese, have cardiovascular disease, high total cholesterol levels, hypertension, or diabetes should undergo a medical evaluation by a physician to determine the appropriateness and safety of the regimen selected, no matter how minor the intended weight loss, and they should be screened and monitored for medical conditions that may be casually linked to weight gain or obesity. Because these guidelines are designed for healthy adults, screening should include assessment for pregnancy, binge eating, or other eating disorders, psychiatric disorders and medical conditions such as diabetes that might be exacerbated by alterations in energy intake and shifts in nutrient distribution. In addition to a full medical history and physical examination, laboratory studies should generally include screening for diabetes, hypertension, renal disease, liver disease, and thyroid function. A lipid panel including measurement of levels of total cholesterol, triglycerides, high density lipoprotein cholesterol, and low density lipoprotein cholesterol should be done. Because physical activity is an important part of effective weight management, the physical evaluation should also determine the safety of a regular exercise regimen.

Original reports were obtained through a MEDLINE search for 1966 through 1992 on very—low-calorie diets or reducing diets plus obesity, supplemented by a manual search of bibliographies and the opinions of experts in the field of nutrition and weight loss therapy for obesity. Only studies of humans were cited.

Current very—low-calorie diets are usually provided in the context of comprehensive treatment programs, during which usual food intake is completely replaced by specific foods or liquid formulas containing 3350 kJ/d (800 kcal/d) or less. Weight loss on very—low-calorie diets averages 1.5 to 2.5 kg/wk; total loss after 12 to 16 weeks averages 20 kg. These results are superior to standard low-calorie diets of 5020 kJ/d (1200 kcal/d), which lead to weight losses of 0.4 to 0.5 kg/wk and an average total loss of only 6 to 8 kg. There is little evidence that intakes of less than 3350 kJ/d (800 kcal/d) result in better weight losses than 3350 kJ. Intake of at least 1 g/kg of ideal body weight per day of protein of high biologic value appears to be important in helping to preserve lean body mass. Serious complications of modern very—low-calorie diets are unusual, cholelithiasis being most common.

Current very—low-calorie diets are generally safe when used under proper medical supervision in moderately and severely obese people (body mass index [weight in kilograms divided by height in meters squared] >30) and are usually effective in promoting significant short-term weight loss, with concomitant improvement in obesity-related conditions. Long-term maintenance of weight lost with very—low-calorie diets is not very satisfactory and is no better than with other forms of obesity treatment. Incorporation of behavioral therapy and physical activity in very—low-calorie diet treatment programs seems to improve maintenance.

Source: National Task Force on the Prevention and Treatment of Obesity. Very low-calorie diets. JAMA. 1993;270:967-974. Adapted with permission.

• Total fat intake should be less than 30% of energy
• Saturated fatty acid intake should be less than 10% of total energy
• Polyunsaturated fatty acid intake should be no more than 10% of total energy
• Monounsaturated fatty acid intake should make up the rest of total fat intake, about 10% to 15% of total energy
• Cholesterol intake should be no more than 300 mg/d
• Sodium intake should be no more than 3000 mg (3 g) per day

The AHA dietary guidelines include the following recommendations for food selection:

• No more than 5 to 8 teaspoons of fats and oils per day, including the fats used in cooking and baking and in salad dressings and spreads
• Six ounces or less of lean meat, fish, or skinless poultry
• No more than three or four egg yolks per week
• Two to four servings of nonfat or low-fat milk and dairy products per day
• Five or more servings of fruits and vegetables per day
• Six or more servings of breads, cereals, rice, pasta, other grains, and starchy vegetables per day

Behavior modification can be used to help a person develop and maintain a healthy lifestyle. Among its principles are self-monitoring, stimulus control, use of rewards, stress management, cognitive-behavioral strategies, problem solving, relapse prevention approaches, and social support.

Self-monitoring (through food and exercise diaries) involves identification and recording of behaviors targeted for change.

Stimulus control is the identification and modification of environmental cues associated with overeating or underexercising.

Rewards can be used when habits are changed (eg, increasing the number of minutes exercised).

Stress management can be used to help people cope with affective factors that interfere with healthful eating.

Cognitive-behavioral strategies (eg, cognitive restructuring) are aimed at modifying attitudes, beliefs, and perceptions that prevent the adoption of appropriate eating and exercise habits.

Problem solving and relapse prevention approaches help people maintain appropriate behavioral changes over the long term.

Self-efficacy is a person's belief that he or she has the behavioral skills to cope successfully with high-risk situations.

"American Heart Association Guidelines for Weight Management Programs for Healthy Adults" was approved by the Steering Committee of the American Heart Association on February 16, 1994.

Requests for reprints should be sent to the Office of Scientific Affairs, American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231-4596.

Heart Disease and Stroke. 1994;3:221-228.