The intervention program evaluated in the current analysis was effective in improving a range of health outcomes in INT compared to CON and that are described elsewhere . Despite an average of approximately two thirds of sessions attended overall, this was sufficient to improve diet, increase PA and produce clinically relevant outcomes in free-living individuals with MetS. This suggests that the methods and delivery of this program were acceptable. Also, the content and structure of the program has to some extent been reported as acceptable by participants.
The content of the education program was based upon Australian national guidelines. There is recent evidence to suggest that lifestyle intervention in accordance with general lifestyle recommendations can be beneficial to health in at-risk individuals [15, 18, 20] when delivered by health professionals/lifestyle counsellors. In order to achieve clinically significant outcomes through our group-based approach, we hypothesised that promoting dietary quality would result in a more balanced, nutrient-dense diet, with increased complex carbohydrate, bioactive nutrient and fibre intake, together with reduced total energy intake. Additionally we hypothesised that benefit may be gained by introducing participants to the 'functional' aspects of recommended foods (low GI, omega-3), for which the evidence-base relating to health benefits is increasing [51–54]. Our intervention program provided a simple, group-based approach to improving diet and PA, and essentially provided a strategy for encouraging adoption of the national recommendations. Consequently this intervention may be more easily transferred into communities than complicated or restrictive diets and personalised or prescribed exercise, which are generally unsustainable.
The overall aim of the PA component of the intervention was to increase energy expenditure and promote overall fitness by increasing moderate/vigorous exercise and incidental/low intensity (long-duration) leisure activity in accordance with national guidelines. We encouraged engagement in regular PA in order to achieve not only body fat reduction, but also to improve risk factors which constitute the metabolic syndrome. [55, 56]
We also proposed that self-management techniques, that have proven successful in the management of chronic disease, might also be applicable in managing overweight [26, 57]. Lifestyle topics and strategies were incorporated to address some of the external and personal issues that are often barriers to healthy lifestyle choices. The activities incorporated were adapted from other successful SMP's described previously. The effectiveness of the Stanford techniques for chronic disease have been demonstrated internationally [21, 58] and locally .
The literature suggests that programs combining diet, exercise, and behaviour modification are the most effective for improving health outcomes in the short term  (as cited in ). Self-managed strategies are also useful in the management of weight  and are considered to apply especially well to preventive interventions involving lifestyle modification . In our program, practical sessions and supervised exercise were included to address 'real-life' aspects of dietary choice and PA, and to introduce participants to different options to consider. Self-efficacy is also recognised as associated with health behaviour change  and current evidence continues to confirm it's importance to diet and activity . Therefore action planning and problem solving were integral to the program to promote self-efficacy; through accomplishing small, weekly behavioural goals which would lead to achieving a larger health-related goal.
Program format and conduct
Recent data has indicated that group-based lifestyle intervention with monthly follow-up can improve body weight, PA, health and wellbeing to a similar extent as individualised dietetic treatment.  In our program, group meetings were conducted for all sessions. A group setting was used to more effectively manage a number of individuals over time, compared one-on-one individual interventions . A similar strategy has also been recently described for engaging larger groups of individuals; through adaptation of the DPP intervention for delivery in the community . Additionally there is evidence to show that the social support network may assist individuals in maintaining weight loss through continued follow-up , shared short-term goal setting and problem solving , which is also why we considered the peer-group setting to be a useful strategy. The presence of a peer leader endeavouring to achieve the same lifestyle goals as the other participants also provided a source of collegial support.
Program duration and follow-up
Based upon published outcomes of the American and Finnish Diabetes prevention studies [7, 65], and other trials conducted in our research clinic  we considered that a 4 month period was sufficient to demonstrate the effect of the intervention on study outcome measures. In order to maximise the potential benefit of the intervention, but without over-burdening participants, education meetings were scheduled weekly for 1 hour with 45–60 min exercise following. Frequency of contact was adapted from the 'Lifestyle balance' program by the Diabetes Prevention Program Research Group (DPPRG), the aims of which were weight loss and increased PA. Weekly contact in initial stages is accepted as standard for weight loss interventions . These and other reports suggest that individuals are more likely to maintain lifestyle changes if they have regular follow-up . [67–70]
Assessments of compliance revealed that the program was well tolerated. The gradual decline in attendance appearing approximately half-way through may suggest 'program fatigue', but no further data is available to support this. Interventions of longer duration tend to have greater attrition  and more than 50% dropout might be expected in community-based interventions . Although commitment to weekly sessions may have been at times difficult to manage for participants, it appears that these compliance rates are acceptable. To compare with other lifestyle interventions [15, 48–50], we might expect average attendance of 75% to information, and 50% to exercise sessions, so attendance to our information sessions was consistent with other studies, and exercise adherence slightly better. Attendance to information tended to predict attendance to group exercise, which may indicate that the format of the program was useful in encouraging participation in exercise, as participants may have been more likely to join in group exercise or use the gym (directly after the information session). Some have suggested the use of home-based exercise equipment as a means to improving adherence in overweight adults, especially women  which appears to be consistent with the feedback reported by participants during focus groups. Some research indicates that although home-based training is not as effective at improving factors such as glycemic control, it is effective for maintaining improvements in muscle strength and lean body mass following gymnasium-based training .
Compliance with self-reports were poorly completed, with only one-third of participants returning a reasonable record of weekly PA and food serves consumed. Adherence to self-monitoring during lifestyle intervention is a complex issue and is notoriously sub-optimal , which is consistent with other weight-management studies [12, 74].
Our understanding of participants' perceived lifestyle changes and reasons for being involved is limited to a small sample of responses. Despite this, some common themes were identified that appear to support the major aims of the program but this may be biased due to the most motivated individuals attending focus groups, and also because responses were collected during the intervention. For perceived lifestyle changes, most frequent responses were around specific dietary changes, and engagement in formal exercise (including resistance exercise and trying new activities) and incidental PA. Other interesting comments included feelings of self-discipline, self control, motivation and the formation of better habits. Although it is difficult to extrapolate from this small sample of responses, it appeared that the main motivations given for participating were not simply to 'lose weight', but to modify size, health risk factors and lifestyle habits. This may be suggesting that individuals taking on lifestyle changes were seeing a bigger picture than actually making dietary and activity adjustments.
Results from the focus-group indicated that there was significant value in certain aspects of the dietary education provided, including food-label reading, cooking, and nutritional composition of packaged foods. There was also interest in specific information on serving sizes and daily allowances, which may have benefitted the more motivated individuals to better understand their required energy intake. Participants also suggested more instruction for home-based exercises. Participants considered peer-leadership to be important and interactive sessions more valuable than a didactic format, and the peer-group setting was important for collegial support. Learning and applying self-management skills was also found to be useful. Clinical monitoring, progress checks and continued support were also identified as vital for continued motivation. The acknowledgement of psychological counselling is not a surprising finding owing to the complex nature of obesity and the underlying issues that present barriers to healthy lifestyle.
Participants commented that the session content was appropriate to the level of understanding of the participants, and participants consequently were empowered to make behavioural changes. Increased feelings of wellbeing and achievement were noted as a result. It was identified that there is a need to focus on maintenance and support of these behaviours after the cessation of the intervention, including clinical assessment and social support networks.
A simpler strategy for lifestyle modification?
Community or population level interventions need to be simple and inexpensive to be cost effective. The Ottawa charter for health promotion (WHO) states that healthy choices should be the easy choices  and there is further evidence emerging that this may empower individuals to continue making the healthy choices . This is an important consideration in this context, where the ultimate goal is to avoid preventable lifestyle disease. This study was predicated on the assumption that the usual dietary restriction and high levels of PA to counter overweight are difficult for the general population to sustain . Our approach was to implement a program based on dietary and PA guidelines that were already in place, and to assess its effect on clinical outcomes in comparison to a control group who were simply provided with the guideline documents.
This study also confirms that simply providing written guidelines to CON was not sufficient to effect significant change in dietary and physical activity behaviour. The implication of this is that the current practice of government and other organisations to develop and disseminate written guidelines will not of itself address the needs of overweight individuals. Rather these guidelines are best accompanied by additional support strategies including active behavioural intervention and practical examples that translate guidelines into everyday strategies that assist individuals from different backgrounds in achieving lifestyle recommendations
To our knowledge, this is the first demonstration of a targeted self-management program for individuals who are overweight/obese with MetS, in a randomised controlled trial. Longer-term research is warranted to understand whether a peer-led model would translate into improvements in body composition, cardiovascular risk factors and quality of life, and whether it would be readily accepted in the community. The current intervention has achieved success in the short-term, and analysis of long term clinical and compliance data will contribute to current understandings of the effectiveness of 'modest' lifestyle intervention on body composition and metabolic fitness. The importance of active or follow-up in maintaining improvements will be of particular interest in this assessment. Further research may then be warranted to investigate the sustainability of a similar program in a peer led, community-based setting.