Obesity is posing a growing threat to public health throughout the world and places extra burden on health costs. According to the Population Health Survey conducted in 2004 in Hong Kong, 38.8% of population was overweight and 21% were obese [1]. These figures of overweight in adulthood have doubled since 2003. This is a major cause of concern as obesity is often related to other health risks such as cancer, heart disease, diabetes, dyslipidemia, hypertension and stroke. While prevention is clearly important, effective management of those with obesity continues to be a public health challenge.

Common management options consist of lifestyle modification in terms of diet and physical activity, pharmacological methods, and surgery for the morbidly obese [2]. It has been proposed that a weight management and treatment algorithm should consist of diet, exercise and behavioral therapy. As a result, numerous commercial and proprietary weight loss programs have been introduced [3]. Studies have shown that crucial to the success of most programs is the inclusion of a component of behavioral modification [2,4].

Most commercial weight loss programs in Hong Kong offer a range of options from very low calorie exchange diets, meal replacement products, supplements or unbalanced meals. Often these may be unaffordable for many people or carry claims of unrealistic weight loss. The Lifestyle Modification Program (LMP) examined in this study is a self-help community based program in Hong Kong for those who are overweight or obese. It provides low calorie exchange diets, physical and behavioral weight control methods individualized by nutritionists during counseling sessions. The purpose of the LMP is to develop lifestyle behaviors that encourage increasing caloric expenditure while decreasing caloric intake, with an emphasis on long term lifestyle and behavior change. Cognitive behavior therapy (CBT), which is derived from cognitive and behavioral psychological models of human behavior that include theories of normal and abnormal development, and theories of emotion and psychopathology, is applied as the strategy on behavior modification in the LMP [5]. Five levels of influence were identified by McLeroy and colleagues [6] for health-related behaviors and conditions. These levels include: (1) intrapersonal or individual factors; (2) interpersonal factors; (3) institutional or organizational factors; (4) community factors; and (5) public policy factors. The LMP highlights the importance of collaboration between clients and nutritionists to identify and understand the problems in terms of relationship between thoughts, feelings and behavior, to find out solutions, and to test and re-test those solutions is important for cognitive and behavior changes. The LMP therefore focuses on exploring the intrapersonal factors and the interpersonal factors that influence the clients to make lifestyle changes. Intrapersonal factors, such as knowledge, attitudes, beliefs, and personality traits; and interpersonal factors, such as the social network and social support systems are identified by the LMP nutritionists for cognitive and behavior changes [6]. A process of change may be involved, in which clients adjust their attitudes to the problems, consider the consequence of the problems and assess self-confidence in relation to a possible change [7]. The LMP also highlights the use of patient-centered approach in the counseling process. Patient-centered approach can be defined as involving the health professional trying to understand how the patients view their problems, and working on potential solutions together to culminate in the patient feeling they have developed their own realistic plans for change [8]. Five main domains are advocated in the patient-centered approach, which include (1) exploring the patients’ main reason for the visit, concerns, and need for information; (2) seeking a comprehensive understanding of the patient’s personal, developmental and family issues; (3) finding common ground on what the problem is and mutually agrees on management plan; (d) enhancing risk reduction and health promotion; and (e) enhancing the continuing relationship between the patient and the therapist [9,10].

As lifestyle modification is a complex process, which involves both behavioral and cognitive changes [11], multiple theories are combined in the CBT of the LMP. These theories include the Health Belief Model [12], which addresses the individual’s perceptions of the risk posed by a health problem (susceptibility, severity), the benefits of avoiding the risk, and factors influencing the decision to act (barriers, cues to action, and self-efficacy), the Stages of Change Model [13], which describes individuals’ motivation and readiness to change a behavior, the Social Cognitive Theory [14], which describes a dynamic, ongoing process in which personal factors, environmental factors, and human behavior exert influence upon each other, and the Consumer Information Processing Theory [15], which postulates that information must not only be available but also believed to be useful and format-friendly to the consumer.

The effectiveness of lifestyle modification for the treatment of obesity has been assessed recently [4,16]. However, most studies focus on measurable health outcomes, such as weight loss and change in body fat percentage, and there is little information about how clients attending lifestyle modification programs view the outcomes and how such programs impact upon their lifestyle and behavior. Although it has been recognized that the views of the client should be included in outcome measurement [17], little information is available in the literature related to client involvement in evaluating the outcomes of lifestyle modification programs [18,19]. The purpose of this study was to obtain views of clients attending a community based LMP on lifestyle and behavior change, in order to facilitate continuing development of the whole service in supporting individuals to make sustainable lifestyle changes.

Our results suggested that clients perceived the LMP had positive impacts on client’s health, nutrition and health knowledge. Meanwhile, the findings showed that clients experienced both psychological and environmental barriers for lifestyle and behavior change throughout the LMP, and the nutritionists’ capability of providing professional information and psychological support was important element for helping clients overcome such barriers.

Lifestyle modification is a complex process, which involves both behavioral and cognitive changes [11]. A process of change may be involved, in which clients adjust their attitudes to the problems, consider the consequence of the problems and assess self-confidence in relation to a possible change [7]. The cognitive behavior therapy emphases the collaboration between clients and nutritionists to identify and understand the problems in terms of relationship between thoughts, feelings and behavior, to find out solutions, and to test and re-test those solutions is important for cognitive and behavior changes [5]. This study identified several psychological factors and environmental factors as barriers to lifestyle modification. Psychological barriers, including frustration, negative emotions, lack of trust in own ability to succeed, loss of confidence in the nutritionist’s ability to provide an effective intervention, pressure from others; and environmental barriers from workplace and restaurants described by our clients, were in line with previous studies [24–26]. Jones et al. collected obese adults’ views on the dietetic service in West of Scotland for weight management in a qualitative study. Similar psychological factors were identified as to our findings. These factors included depression, frustration, negative emotions, stress, lack of motivation, hating to feel committed, and a lack of trust in their ability to succeed or monitor themselves. Although our study and Jones’ study identified a lack of healthy eating facilities and meals out in restaurants as environmental barriers to lifestyle changes, Jones’ study also suggested other factors as barriers to lifestyle change. These factors included cost of healthy food choices and physical elements, such as age, medical problems, and food allergies and intolerances, which were not reported by the clients in our study [25]. However, as with our study, pressure from others and lack of social support were identified as one of the important barriers to lifestyle changes in obese people in different cultural settings [25,28].

Most participants commented that the LMP had positive impacts on their health and nutrition knowledge. These impacts are essential for lifestyle modification as people would change behavior if they come to believe that the change is both of value and achievable [27]. The resulting improvements in health and physical function reported in this study and previous studies [28,29] were regarded as important motivators for lifestyle modification. These improvements included dietary-related problems, such as reduced cholesterol and reduced blood pressure, decreased clothes size, and feeling lighter as reported in our study and previous studies [25,29]. Previous studies also identified improvements in mood, self-esteem, confidence and social lives as other motivators for lifestyle change [25,29].

The LMP clients commented that a good nutritionist should be able to give clear and practical advice and psychological support. These comments were supported by previous work that health professionals should avoid prescribing healthy lifestyles that a patient should follow, but should act as a coach to encourage patients to explore their motivations, and to empower them develop their own healthy lifestyles [30,31]. Findings of previous studies comparing the effectiveness between a lifestyle modification program and a standard dietetic care also suggested that the inclusion of behavioral change approach and motivational interviewing on top of just giving diet and exercise advice was important for weight management and maintenance [2,32]. Patient-centered approach and various behavioral change techniques, such as expressing empathy, supporting self-efficacy and exploring client’s readiness to change, were the key elements of a lifestyle modification program [32,33].

The outcomes of behavioral treatment are influenced by the behavior of the health professional [34], and there is evidence from an obesity treatment program showing that only those dietitians with the appropriate interpersonal skills, expertise and training should undertake weight management program [33]. Training in techniques, including reflective listening skills by using reflective statements [30,35], skills for new adaptive learning and management relapses [8], techniques for involving the patient in active problem solving [30] and building up a collaborative relationship with client [30], are important for facilitating behavioral change [33]. Our results indicated that the LMP nutritionists were able to integrate different behavior change theories in the counseling process, and were generally able to fulfill the clients’ expectation of being a good nutritionist. Most participants in this study valued the LMP nutritionists as a good information guide, and being able to give clear and practical dietary advice. These comments were in line with the Consumer Information Processing Theory, which postulates that information must not only be available but also believed to be useful and format-friendly to the consumer [15]. Our clients also commented that the LMP nutritionists were flexible in adjusting diet plans and refining goals tailored to the client’s situation, and they valued the psychological support, such as on-going encouragement, patience, and acceptance from the LMP nutritionists. These techniques may increase client’s self-efficacy in making behavioral changes, which reflected the integration of the Social Cognitive Theory in the counseling process. The Social Cognitive Theory states that if individuals have a sense of self-efficacy, they can change behaviors even when faced with obstacles. If they do not feel that they can exercise control over their health behavior, they are not motivated to act, or to persist through challenges [14]. Findings of a previous study also showed that clients valued the counseling skills of dietitian. In a qualitative study exploring obese adults’ views on the dietetic service, interviewees valued the professional support, motivation and encouragement that they received from the dietitian, and described that the dietitian was “somebody there that would listen to you”. The interviewees also commented that the dietary advice was practical and easy to follow [25].

The importance of patient-centered care has been increasingly advocated for health care practice [36,37]. There is also evidence that involving patients in decision making can improve a variety of health outcomes in diverse settings [38,39]. Our data showed that clients came across a wide spectrum of psychological and environmental barriers in the LMP, but their appreciation on the technical and psychological support from the nutritionists highlighted the value of patient-centered care offered in the LMP. However, similar to previous findings, time constraint and staff skillfulness in delivering consultations were claimed by our clients as main factors influencing client understanding and consequent satisfaction [37,40]. Previous studies examining the relationship between consultation length and outcomes in general practice showed that longer consultations were significantly associated with better recognition and handling of problems, and with better patient enablement [41,42]. However, it has been suggested that patients’ perceptions of consultation length were influenced not just by actual consultation length, but by their experience (i.e. the quality) of the consultations [43]. Therefore, it has been suggested that the focus of quality should shift from ‘how much time’ to ‘how best to use that time’ [44].

There are limitations in this study. Subjects in this study were recruited on voluntary basis and they may be prone to have more positive views about the LMP. However, the interviewers recruited these subjects on random days and consultation slots, which were unknown to the nutritionists. This could help minimize the sampling bias in this study. However, the views collected in this study may not be generalized to the general population due to the stated recruitment procedures. The sample size was also small and consisted of mainly women. It should be noted that the aim of this study was not to make generalizations about the population from which the sample was drawn, but rather to explore the views of clients attending a community based LMP.

Effective lifestyle modification programs in routine clinical care and community setting have enormous potential in response to the increasing public health problem of obesity and related diseases. This study demonstrates that clients valued the positive impacts on their health and nutrition knowledge, and the nutritionists’ efforts offered in a community based lifestyle modification program. The results also imply that the nutritionist’s capability of providing quality consultations and patient-centered care is important for empowering clients to achieve lifestyle modification.