11 MN The Nutrition and Treatment of Obesity Bruckner.ppt Nutrition... · Health Stroke Consequences of Obesity Liver Disease Diabetes Heart Disease Colon Cancer Heart Disease

The Nutrition and Treatment of ObesityThe Nutrition and Treatment of Obesity

Geza BrucknerGeza BrucknerClinical NutritionClinical [email protected]@uky.edu

ObjectivesObjectives

1. Review the nutritional etiology of obesity1. Review the nutritional etiology of obesity2. Establish the relevance of diet therapy for obesity.2. Establish the relevance of diet therapy for obesity.3. Explore the metabolic barriers to weight loss as well 3. Explore the metabolic barriers to weight loss as well

as the different types of dietary interventions.as the different types of dietary interventions.4. Effective diagnosis and treatment strategies4. Effective diagnosis and treatment strategies

–– NutritionNutrition–– ExerciseExercise

5. Identify other diet therapies for obesity5. Identify other diet therapies for obesity

Obesity Management in an Obesity Management in an O i Offi P iO i Offi P i

PatientPatientBMIBMI

Outpatient Office PracticeOutpatient Office PracticeBMIBMI

4040 3131 2727 2020

3737

33332121

2929

Appropriate Office Environment for Obese PatientsAppropriate Office Environment for Obese Patients

•• Waiting room chairs without armsWaiting room chairs without arms

•• Step stools next to examination tablesStep stools next to examination tables

L d bl d ffL d bl d ff•• Large gowns and blood pressure cuffsLarge gowns and blood pressure cuffs

•• Scale that can weigh extremely obese patients, Scale that can weigh extremely obese patients, located in a private arealocated in a private area

•• Appropriate obesity educational materials, Appropriate obesity educational materials, pp p y ,pp p y ,handouts, and treatment protocolshandouts, and treatment protocols

•• Empathetic, respectful, and supportive office staffEmpathetic, respectful, and supportive office staffEmpathetic, respectful, and supportive office staffEmpathetic, respectful, and supportive office staff

Initial Office VisitInitial Office VisitInitial Office VisitInitial Office Visit

•• Include evaluation of potential obesity related diseases within history,Include evaluation of potential obesity related diseases within history,Include evaluation of potential obesity related diseases within history, Include evaluation of potential obesity related diseases within history, physical examination, and laboratory testsphysical examination, and laboratory tests

•• Obtain weight history, eating, and activity behaviorsObtain weight history, eating, and activity behaviorsS h f t i i f t i l di di tiS h f t i i f t i l di di ti•• Search for triggering factors, including medicationsSearch for triggering factors, including medications

•• Measure weight, height, waist circumference and calculate body mass Measure weight, height, waist circumference and calculate body mass indexindex

•• Categorize obesity classification and health riskCategorize obesity classification and health risk•• Determine readiness to lose weightDetermine readiness to lose weight

I iti t t t t l (i l th f i l d d)I iti t t t t l (i l th f i l d d)•• Initiate treatment plan (involve other professionals as needed)Initiate treatment plan (involve other professionals as needed)•• Discuss goals and expectationsDiscuss goals and expectations•• Arrange followArrange follow--up and supportup and supportgg p ppp pp

Kushner and Weinsier. Med Clin North Am 2000;84:387.

Key Food TriggersKey Food TriggersKey Food TriggersKey Food Triggers

•• BoredomBoredom•• Being aloneBeing alonegg•• Being in companyBeing in company•• TVTV•• TVTV•• HolidaysHolidays•• WeekendsWeekends•• Habitual routine, etc.Habitual routine, etc.,,

Assessing Weight Loss ReadinessAssessing Weight Loss Readinessg gg g

•• Motivation:Motivation: Patient seeks weight reductionPatient seeks weight reductionMotivation:Motivation:•• Stress level:Stress level:•• Psychiatric issues:Psychiatric issues:

gg

Free of major life crisesFree of major life crises

Free of severe depression, substance Free of severe depression, substance •• Psychiatric issues:Psychiatric issues:

•• Time availability:Time availability:

abuse, bulimia nervosaabuse, bulimia nervosa

Patient can devote 15Patient can devote 15--30 min/d to weight 30 min/d to weight control for next 26 weekscontrol for next 26 weeksTime availability:Time availability:

Patient Ready?Patient Ready?Patient Ready?Patient Ready?YESYES NONO

Prevent weight gain Prevent weight gain and explore barriers to and explore barriers to

Initiate weight loss Initiate weight loss therapytherapy

weight reductionweight reduction

FactoidsFactoidsFactoidsFactoids• Obesity is a chronic disease

• Modest weight loss (5% -10% of body weight) can have considerable medical benefits

• Lifestyle change (diet and physical activity) is the cornerstone of therapy

• Pharmacotherapy can be useful in properly selected patientspatients

• Bariatric surgery is the most effective therapy for t III Ob ittype III Obesity

StrokeStrokeHealth Health Consequences Consequences qqof Obesityof Obesity

Liver DiseaseLiver DiseaseDiabetesDiabetes

Heart DiseaseHeart DiseaseColon CancerColon Cancer

Heart DiseaseHeart Disease

Osteoarthritis

http://www.24kt.us/Fatbig.jpg

Health Consequences of ObesityHealth Consequences of Obesity

MentalMental MechanicalMechanical MetabolicMetabolic-- depressiondepression-- anxietyanxiety

-- osteoarthritisosteoarthritis--obstructive obstructive sleep apneasleep apnea

-- diabetesdiabetes-- dyslipidemiadyslipidemia

fatty liverfatty liver-- personality personality

disorderdisorderlf tlf t

sleep apneasleep apnea-- reflux diseasereflux disease-- urinary incontinenceurinary incontinence

-- fatty liverfatty liver-- hypertensionhypertension-- cancercancer

-- self esteemself esteem-- etc.etc.

-- intertrigointertrigo-- etc.etc.

-- PCOSPCOS-- gall bladdergall bladder-- infertilityinfertilityyy-- etc.etc.

Cause of Obesity: ImbalanceCause of Obesity: ImbalanceCause of Obesity: ImbalanceCause of Obesity: Imbalance

BAGELBAGEL20 Years Ago Today

140 l i H l i140 calories 3-inch diameter

How many calories are in this bagel?

BAGELBAGEL20 Years Ago Today

140 calories 350 calories140 calories 3-inch diameter

350 calories6-inch diameter

Calorie Difference: 210 calories

Maintaining a Healthy Weight is a Balancing ActCalories In = Calories OutCalories In Calories Out

How long will you have to rake leaves in order to burn the extra 210 calories?*burn the extra 210 calories?*

*Based on 130-pound person

Calories In = Calories Out

If you rake the leaves for 50 minutes you will burn the extra 210 calories.*


CHEESEBURGER20 Years Ago Today

590 calories333 calories




If you lift weights for 1 hour and 30 minutes,you will burn approximately 257 calories.*


SPAGHETTI AND MEATBALLS20 Years Ago Today

1,025 calories2 cups of pasta with sauce and 3 large meatballs

500 calories1 cup spaghetti with sauce and 3 small meatballs



If you houseclean for 2 hours and 35 minutes, you will burn approximately 525 calories.*


FRENCH FRIESFRENCH FRIES20 Years Ago Today

610 Calories6.9 ounces

210 Calories2.4 ounces

Calorie Difference: 400 Calories


If you walk leisurely for 1 hour and 10 minutesyou will burn approximately 400 calories.*


TURKEY SANDWICHTURKEY SANDWICH20 Years Ago Today

C l i Diff 500 l i




If you ride a bike for 1 hour and 25 minutes,you will burn approximately 500 calories.*


Factors contributing to gradual weight gainFactors contributing to gradual weight gainFactors contributing to gradual weight gainFactors contributing to gradual weight gain

• Most individuals gradually gain weight over a long period• Most individuals gradually gain weight over a long period of time; often without realizing they have changed their behaviors

• These changes could be very small, e.g. an excess of only 10 Kcal/d could result in a weight gain of ~1 lb/yr ~10 lbs in 10 years10 years

• The modern environment has taken successful body-weight control from an instinctual (unconscious) process toweight control from an instinctual (unconscious) process to one that requires cognitive skill and effort, and that individuals who are not devoting substantial conscious effort to managing body weight are probably gainingeffort to managing body weight are probably gaining weight. (Obesity Reviews 2002;3, 69–74.)

Classification of Overweight and Obesity by BMI

Obesity Class BMI kg/m2

Classification of Overweight and Obesity by BMI

y gUnderweight <18.5

Normal 18 5–24 9Normal 18.5 24.9

Overweight 25–29.9

Obesity I 30.0–34.9

II 35.0–39.9

Extreme Obesity III 40.0

Obesity TreatmentObesity TreatmentObesity TreatmentObesity Treatment

Obesity IIIObesity IIISurgerySurgery

Obesity IIObesity II

Obesity IIIObesity III

PharmacotherapyPharmacotherapy

Lifestyle ModificationLifestyle ModificationObesity IObesity I

yyOverweightOverweight

Obesity Treatment: Not Simple!Obesity Treatment: Not Simple!Obesity Treatment: Not Simple!Obesity Treatment: Not Simple!

Selected Medications That Can Selected Medications That Can C W i h G iC W i h G iCause Weight GainCause Weight Gain

•• Psychotropic medicationsPsychotropic medications Diabetes medicationsy py p–– Tricyclic antidepressantsTricyclic antidepressants

–– Monoamine oxidase Monoamine oxidase

– Insulin– Sulfonylureas

Thi lidi diinhibitorsinhibitors

–– Specific SSRIsSpecific SSRIs

At i l ti h tiAt i l ti h ti

– Thiazolidinediones

Highly active antiretroviral therapy–– Atypical antipsychoticsAtypical antipsychotics

–– LithiumLithium

Specific anticonvulsantsSpecific anticonvulsants

therapy

Tamoxifen

St id h–– Specific anticonvulsantsSpecific anticonvulsants

•• --adrenergic receptor adrenergic receptor blockersblockers

Steroid hormones– Glucocorticoids– Progestational steroidsProgestational steroids

How Important are Genetic Factors How Important are Genetic Factors in the Development of Obesity?in the Development of Obesity?in the Development of Obesity?in the Development of Obesity?

Harris AM et al. Obesity 2006;14:690-695

Hurdles of Weight LossHurdles of Weight LossHurdles of Weight LossHurdles of Weight Loss

•• Body tries to maintain fat stores by regulating theBody tries to maintain fat stores by regulating theamount of food and calories consumed.amount of food and calories consumed.

•• Research with animals and humans has found that aResearch with animals and humans has found that aperson has a programmed “set point” weight.person has a programmed “set point” weight.

•• The existence of this set point helps to explain whyThe existence of this set point helps to explain whymost diets do not workmost diets do not workmost diets do not work.most diets do not work.

•• In addition, their set point is now set at a higher level,In addition, their set point is now set at a higher level,making it even more difficult to lose weight.making it even more difficult to lose weight.“ h ff ” d ““ h ff ” d “ di i ”di i ”•• “Ratchet effect” and “yo“Ratchet effect” and “yo--yo dieting”.yo dieting”.

•• The key to The key to overcoming the fat cell’s set point appearsovercoming the fat cell’s set point appearsto be increasing the sensitivity of the fat cells to insulin.to be increasing the sensitivity of the fat cells to insulin.g yg y

ControlControlControlControlof Energy of Energy MetabolismMetabolismMetabolismMetabolism

The status of the HPA axis in relation to The status of the HPA axis in relation to visceral obesity, glucose, insulin, and lipids.visceral obesity, glucose, insulin, and lipids.

Rosmond Med Sci Monit, 2003; 9(2): RA35-39

Rosmond: Med Sci Monit, 2003; 9(2): RA35-39

Reactivity profiles of high and low Reactivity profiles of high and low reactors during stress session.reactors during stress session.

Epel et al. Psychoneuroendocrinology 26 (2001) 37–49

Raw mean calories consumed by reactivity Raw mean calories consumed by reactivity group on stress and control daysgroup on stress and control days

Epel et al. Psychosomatic Medicine 62:623632 (2000)

FactoidsFactoidsFactoidsFactoids

• Healthy active living is important at any weightHealthy active living is important at any weight•• Maintenance of healthy eucaloric diets andMaintenance of healthy eucaloric diets and

physical activity are essential to prevent weight gainphysical activity are essential to prevent weight gain•• Once established, obesity is a chronic diseaseOnce established, obesity is a chronic disease

and requires longand requires long--term management and treatmentterm management and treatment•• Weight alone is a poor indicator of body fat orWeight alone is a poor indicator of body fat org p yg p y

related health risksrelated health risks

Systematic Review of Weight Loss StudiesSystematic Review of Weight Loss StudiesAverage Weight Loss of Subjects Completing a MinimumAverage Weight Loss of Subjects Completing a MinimumAverage Weight Loss of Subjects Completing a Minimum Average Weight Loss of Subjects Completing a Minimum 11--Yr Weight Management InterventionYr Weight Management Intervention80 Studies, 24, 698 Subjects, 16,823 Completers (68%)

0

2

-6

-4

-2

(kg)

-12

-10

-8

Wei

ght L

oss

(

Exercise Alone

18

-16

-14

12W Diet + ExerciseDiet A loneM eal ReplacementsVLCDOrlistat

-20

-18

1 2 3 4 5 6

SibutramineAdvice Alone

6-mo 12-mo 24-mo 36-mo 48-mo

Popular DietsPopular Diets CompositionCompositionPopular Diets Popular Diets -- CompositionComposition

DietDietProgramProgram

Kcal Kcal CHO CHO (%)(%)

Kcal Kcal Pro Pro (%)(%)

Kcal Kcal Fat Fat (%)(%)

Kcal Sat Kcal Sat Fat Fat (%)(%)

Chol Chol (m(mg)g)

Fiber Fiber (g(gm)m)Program Program (%) (%) (%) (%) (%) (%) (%) (%) g) g) m) m)

Atkins Atkins 55 3535 5959 2626 924924 44“P t i“P t i“Protein “Protein

Power” Power” 88 3535 5353 1919 657657 1111“Sugar “Sugar gg

Busters” Busters” 4040 2828 3232 99 280280 2424“The “The

Z ”Z ” 3232 2828 3232 77 264264 1818Zone” Zone” 3232 2828 3232 77 264264 1818

Ornish Ornish 7474 1818 77 22 3030 4949

Evidence Model for Treatment of Overweight and Evidence Model for Treatment of Overweight and ObesityObesityObesityObesity

Noncardiovascular Mortality and MorbidityO i ht I di id l

Cardiovascular Disease

Cardiovascular Mortality and MorbidityOverweight Individual

Dyslipidemia Glucose Intolerance

High Blood Pressure

Abdominal W i ht Fit

TreatKcal Out( ( Kcal In ))

Fat Weight Fitness

Assess

Treatment AlgorithmPatient Encounter

1

2g

Hx of 25 BMI?

No

Yes

2

3 BMImeasured in past

• Measure weight, height, and waisti f

Assess risk

4 6

5 7Yes Yes

BMI 25 ORwaist circumference

BMI 30 OR

{[BMI 25 to 29.9 OR waist circumference

p2 years?

circumference • Calculate BMI

Clinician and patientdevise goals andtreatment strategyfor weight loss andrisk factor control

factors

14 12

8

No

Yes

No

YesDoes

> 88 cm (F)> 102 cm (M)

>88 cm (F) >102 cm (M)]AND 2 risk

factors}

Brief reinforcement/ educate on weight management

Advise to maintainweight/addressother risk factors

15 13

9

Yes

No

Hx BMI 25?Yes

No

patient want tolose weight?

Yes

No

Progress being made/goal

achieved?

Examinationmanagement

Periodic weightcheck

other risk factors

Assess reasons forfailure to lose weight

Maintenance counseling: Dietary therapyBehavior therapyPhysical activity:

Treatment11 1016

:

Talking With Patients About Weight Loss: Tips Talking With Patients About Weight Loss: Tips for Primary Care Professionalsfor Primary Care Professionals

•• Patients who were counseled in a primary care setting Patients who were counseled in a primary care setting b h b fi f h l h i d h i lb h b fi f h l h i d h i labout the benefits of healthy eating and physical about the benefits of healthy eating and physical

activity lost weight, consumed less fat, and exercised activity lost weight, consumed less fat, and exercised more than patients who did not receive counselingmore than patients who did not receive counselingmore than patients who did not receive counseling.more than patients who did not receive counseling.

•• St dies sho that short 3St dies sho that short 3 to 5to 5 min te con ersationsmin te con ersations•• Studies show that short 3Studies show that short 3-- to 5to 5--minute conversations minute conversations during routine visits can contribute to patient during routine visits can contribute to patient behavior changebehavior changebehavior change.behavior change.

Talking With Patients About Weight Loss: Talking With Patients About Weight Loss: Tips for Primary Care ProfessionalsTips for Primary Care Professionals

•• Unfortunately, the majority of primary care Unfortunately, the majority of primary care professionals do not talk with their patients professionals do not talk with their patients b t i htb t i htabout weight.about weight.

•• Most people who are overweight or obese Most people who are overweight or obese want assistance in setting and achieving want assistance in setting and achieving

i hti ht l l b t h it t t b hl l b t h it t t b hweightweight--loss goals, but may hesitate to broach loss goals, but may hesitate to broach the topic during office visits.the topic during office visits.

Talking With Patients About Weight Loss: Talking With Patients About Weight Loss: Tips for Primary Care ProfessionalsTips for Primary Care Professionals

•• Explain that you want to help them lose Explain that you want to help them lose p y pp y pweight, reduce their health risks, and make weight, reduce their health risks, and make them feel better, but assure patients that your them feel better, but assure patients that your , p y, p yinterest in their health is not dependent on their interest in their health is not dependent on their success in losing weight. success in losing weight. g gg g

What do patients want from health care What do patients want from health care professionals regarding weight?professionals regarding weight?•• TalkTalk -- before starting a conversation about weight before starting a conversation about weight

control with your patients, allow them to discuss control with your patients, allow them to discuss other issues that may be affecting their physical orother issues that may be affecting their physical orother issues that may be affecting their physical or other issues that may be affecting their physical or emotional wellemotional well--being.being.

•• NonNon--offensive termsoffensive terms -- Patients prefer thePatients prefer theNonNon offensive termsoffensive terms Patients prefer the Patients prefer the terms “weight” or “excess weight,” and dislike terms “weight” or “excess weight,” and dislike the terms “obesity,” “fatness,” and “excess the terms “obesity,” “fatness,” and “excess y, ,y, ,fat.” You may wish to ask your patients what fat.” You may wish to ask your patients what terms they prefer when discussing weight. terms they prefer when discussing weight.

What do patients want from health care What do patients want from health care professionals regarding weight?professionals regarding weight?

•• Advice they can useAdvice they can use –– realistic weight goals, realistic weight goals, specific type of exercise, weight loss specific type of exercise, weight loss p yp , gp yp , gproducts and servicesproducts and services

Which patients might benefit from a Which patients might benefit from a di i b i h ?di i b i h ?discussion about weight?discussion about weight?

•• Approach the subject of weight loss if your patient has:Approach the subject of weight loss if your patient has:–– A body mass index (BMI)* of 30 or above.A body mass index (BMI)* of 30 or above.–– A BMI between 25 and 30 and two or more weightA BMI between 25 and 30 and two or more weight--

related health problems, such as a family history of related health problems, such as a family history of coronary heart disease or diabetescoronary heart disease or diabetescoronary heart disease or diabetes.coronary heart disease or diabetes.

–– A waist measurement over 35 inches (women) or A waist measurement over 35 inches (women) or 40 inches (men)40 inches (men)——even if BMI is less than 25even if BMI is less than 25——and and two or more weighttwo or more weight--related health problems, such as related health problems, such as a family history of coronary heart disease or a family history of coronary heart disease or diabetesdiabetesdiabetes.diabetes.

Tips for Talking About Weight ControlTips for Talking About Weight ControlTips for Talking About Weight ControlTips for Talking About Weight Control

•• Address your patient’s chief health concerns or Address your patient’s chief health concerns or complaints first, independent of weight.complaints first, independent of weight.

•• Address your patient’s chief health concerns or Address your patient’s chief health concerns or complaints first, independent of weight.complaints first, independent of weight.

•• Open the discussionOpen the discussion•• Decide if your patient is ready to control weightDecide if your patient is ready to control weight•• Open the discussionOpen the discussion•• Decide if your patient is ready to control weightDecide if your patient is ready to control weight• Set a weight goal• Prescribe healthy eating and physical activity behaviors• Set a weight goal• Prescribe healthy eating and physical activity behaviors• Follow up.• Follow up.

Dietary approaches in the management Dietary approaches in the management of overweight and obesityof overweight and obesity

• Low-fat diets• L di t• Low-fat diets• L di t• Low-energy diets• Fixed energy deficit (2.5 MJ (600 kcal) • Low-energy diets• Fixed energy deficit (2.5 MJ (600 kcal)

energy deficit from calculated energy requirements)energy deficit from calculated energy requirements)

• Meal replacements• Very-low-energy diets• Meal replacements• Very-low-energy dietsVery low energy dietsVery low energy diets

Weight maintenance skills are distinct from Weight maintenance skills are distinct from those required to achieve weight loss.those required to achieve weight loss.

• The skills required for maintenance phase is • The skills required for maintenance phase is enabling individuals to remain motivated without the powerful reinforcement of losing enabling individuals to remain motivated without the powerful reinforcement of losing weight.weight.

The National Weight Control Registry is the largest study of individuals successful at long-term weightThe National Weight Control Registry is the largest study of individuals successful at long-term weightstudy of individuals successful at long-term weight maintenance. study of individuals successful at long-term weight maintenance. www.nwcr.ws

•• They report that the successful maintainers have the They report that the successful maintainers have the following habits:following habits:

•• They report that the successful maintainers have the They report that the successful maintainers have the following habits:following habits:following habits:following habits:–– 78% eat breakfast every day. 78% eat breakfast every day. –– 75% weigh them self at least once a week.75% weigh them self at least once a week.

following habits:following habits:–– 78% eat breakfast every day. 78% eat breakfast every day. –– 75% weigh them self at least once a week.75% weigh them self at least once a week.75% weigh them self at least once a week. 75% weigh them self at least once a week. –– 62% watch less than 10 hours of TV per week. 62% watch less than 10 hours of TV per week. –– 90% exercise, on average, about 1 hour per day90% exercise, on average, about 1 hour per day

75% weigh them self at least once a week. 75% weigh them self at least once a week. –– 62% watch less than 10 hours of TV per week. 62% watch less than 10 hours of TV per week. –– 90% exercise, on average, about 1 hour per day90% exercise, on average, about 1 hour per day– limiting fast food intake– accepting realistic weigh goals– limiting fast food intake– accepting realistic weigh goals– recognizing that weight control is not ‘painless’ but

requires ongoing commitment– recognizing that weight control is not ‘painless’ but

requires ongoing commitment

LowLow--Calorie Step I DietCalorie Step I DietLowLow--Calorie Step I DietCalorie Step I Dietpppp

NutrientNutrient Recommended IntakeRecommended Intake

CaloriesCalories 500 to 1,000 kcal/day reduction 500 to 1,000 kcal/day reduction


CaloriesCalories 500 to 1,000 kcal/day reduction 500 to 1,000 kcal/day reduction

Total FatTotal Fat 30 percent or less of total calories30 percent or less of total calories

SFASFA 8 to 10 percent of total calories8 to 10 percent of total calories

Total FatTotal Fat 30 percent or less of total calories30 percent or less of total calories

SFASFA 8 to 10 percent of total calories8 to 10 percent of total caloriesSFASFA 8 to 10 percent of total calories8 to 10 percent of total calories

MUFA MUFA Up to 15 percent of total caloriesUp to 15 percent of total calories

PUFAPUFA U t 10 t f t t l l iU t 10 t f t t l l i

SFASFA 8 to 10 percent of total calories8 to 10 percent of total calories

MUFA MUFA Up to 15 percent of total caloriesUp to 15 percent of total calories

PUFAPUFA U t 10 t f t t l l iU t 10 t f t t l l iPUFAPUFA Up to 10 percent of total caloriesUp to 10 percent of total calories

CholesterolCholesterol <300 mg/day<300 mg/day

PUFAPUFA Up to 10 percent of total caloriesUp to 10 percent of total calories

CholesterolCholesterol <300 mg/day<300 mg/day

LowLow--Calorie Step I Diet Calorie Step I Diet (continued)(continued)LowLow--Calorie Step I Diet Calorie Step I Diet (continued)(continued)pppp

ii d d kd d kii d d kd d kNutrientNutrient Recommended IntakeRecommended Intake

ProteinProtein ~ 15 percent of total calories~ 15 percent of total calories


ProteinProtein ~ 15 percent of total calories~ 15 percent of total calories

CarbohydrateCarbohydrate 55 percent or more of total calories55 percent or more of total calories

Sodium ChlorideSodium Chloride No more than 100 mmol/day (~ 2.4 g No more than 100 mmol/day (~ 2.4 g

CarbohydrateCarbohydrate 55 percent or more of total calories55 percent or more of total calories

Sodium ChlorideSodium Chloride No more than 100 mmol/day (~ 2.4 g No more than 100 mmol/day (~ 2.4 g of sodium or ~ 6 g of sodium of sodium or ~ 6 g of sodium chloride)chloride)

C l iC l i 1 000 1 5001 000 1 500

of sodium or ~ 6 g of sodium of sodium or ~ 6 g of sodium chloride)chloride)

C l iC l i 1 000 1 5001 000 1 500CalciumCalcium 1,000 to 1,500 mg1,000 to 1,500 mg

FiberFiber 20 to 30 g20 to 30 g

CalciumCalcium 1,000 to 1,500 mg1,000 to 1,500 mg

FiberFiber 20 to 30 g20 to 30 g

Physical Activityy yRecommended as part of a comprehensive weight loss therapy and maintenance programbecause it:loss therapy and maintenance program because it:

• Modestly contributes to weight lossEvidence Category A.

• May decrease abdominal fat• May decrease abdominal fat Evidence Category B.

• Increases cardiorespiratory fitness Evidence Category A.

Increase Physical Activityy y

• Most important in preventing weight regain p p g g g• Health benefits independent of weight loss• Start slowly and increase gradually• Start slowly and increase gradually

— Can be single session or intermittent— Start with walking 30 minutes 3 days/week— Increase to 45 minutes 5 or more days/week— Encourage increased “lifestyle” activities

10,000 Steps10,000 Steps®® ResultsResults, p, p

•• 25% lose 4 lbs of 25% lose 4 lbs of weight or moreweight or more

•• 25% lose 4 lbs of 25% lose 4 lbs of weight or moreweight or more

10000

10500

11000

11500

(mea

n)

80%

90%

100%

Reco

St ep Tracking 21% increase fro m D ay 1

•• 93% indicate they 93% indicate they would refer the would refer the 10 000 Steps10 000 Steps®®

•• 93% indicate they 93% indicate they would refer the would refer the 10 000 Steps10 000 Steps®®8500

9000

9500

10000

edom

eter

Ste

ps

50%

60%

70%

rded Steps (%

)

St ep A ct ivit y

10,000 Steps10,000 Steps®®

program to a friendprogram to a friend10,000 Steps10,000 Steps®®

program to a friendprogram to a friend7500

8000

1 6 11 16 21 26 31 36 41 46 51 56

Program Day

Pe

30%

40%

0%0

•• On Day 0 (true baseline), On Day 0 (true baseline), participants record on average participants record on average 5,123 number of steps/d.5,123 number of steps/d.22

•• On Day 0 (true baseline), On Day 0 (true baseline), participants record on average participants record on average 5,123 number of steps/d.5,123 number of steps/d.22

VanWormer, J., et al. Diab Spectrum 2006;19(4):197-200.Schneider, et al. Am J Health Promot 2006;21(2):85-89.

, p /, p /, p /, p /

Impact of 10,000 Steps Prescription on Physiological Impact of 10,000 Steps Prescription on Physiological Parameters among Overweight and Obese IndividualsParameters among Overweight and Obese Individualsg gg g

Baseline 20 Weeks 36 Weeks

Hip Circ

HDL•• Single group, repeated Single group, repeated

measures experimental designmeasures experimental design•• Community recruitmentCommunity recruitment

•• Single group, repeated Single group, repeated measures experimental designmeasures experimental design

•• Community recruitmentCommunity recruitment

* +3 mg/dl

* -1.9 cm

FFM

Wcirc•• N=56N=56•• Number of steps:Number of steps:

–– Baseline = 5,123Baseline = 5,123

•• N=56N=56•• Number of steps:Number of steps:

–– Baseline = 5,123Baseline = 5,123

* -1.8 cm

* 0.5 kg

BF%

Fat Mass–– 20 weeks = 9,324 * 20 weeks = 9,324 * –– 36 weeks = 9,117 *36 weeks = 9,117 *

•• No changes in dietNo changes in diet

–– 20 weeks = 9,324 * 20 weeks = 9,324 * –– 36 weeks = 9,117 *36 weeks = 9,117 *

•• No changes in dietNo changes in diet

* -2.7 kg

* -1.9%

Weight

BMI * = statistically significant improvement* = statistically significant improvement* = statistically significant improvement* = statistically significant improvement* -0.8 kg/m2

* -2.4 kg

0 25 50 75 100 125Schneider, et al. Am J Health Promot 2006;21(2):85-89.

Behavior Therapypy

The routine use of behavior therapy strategies to promote diet and physical activity is recommended, as these strategies are helpful in achieving weight loss and weight maintenance. Evidence Category B.

Behavior Therapy (continued)py ( )

Implementation of strategies, based on learning i i l th t id t l f i b i tprinciples, that provide tools for overcoming barriers to

compliance with diet or physical activity changes:• Self monitoring• Self-monitoring• Stress management• Stimulus control• Stimulus control• Problem-solving• Contingency managementContingency management• Cognitive restructuring• Social supportpp

Self-Monitoringg

Keep records of:Keep records of:

• Amount and types of foods eatenyp

• Frequency, intensity, and type of q y y ypphysical activity

• Time, place, and feelings

Stress Managementg

Defuse situations that lead to overeating:Defuse situations that lead to overeating:

• Coping strategiesCoping strategies

• MeditationMeditation

• Relaxation techniquesq

Stimulus Control

Behavior change techniques:Behavior change techniques:

• Learn to shop for healthy foods.p y

• Keep high-calorie foods out of the home.p g

• Limit the times and places of eating.

Cognitive Restructuringg gRational thoughts designed to replace negativethoughts:Instead ofInstead of. . .

“I blew my diet this morning by eating that doughnut ”doughnut.”

Use. . . “Well, I ate the doughnut, but I can still eat in a

healthy manner the rest of the day.”

Social SupportSoc Suppo

Maintain motivation and positiveMaintain motivation and positive reinforcement:

• Family

• Friends

• Colleagues

Optimizing Practice through ResearchOptimizing Practice through Researchp g gp g g

•• WeighWeigh--ByBy--Day Trial Day Trial –– an effectiveness trialan effectiveness trial–– HomeHome--based scale connected via telephone line to health based scale connected via telephone line to health

coach allows for measurement of body weightcoach allows for measurement of body weight–– Frequency of selfFrequency of self--weighing a significant predictor for weighing a significant predictor for

i ht li ht lweight lossweight loss–– Participants lost about 5 extra pounds of weight for every Participants lost about 5 extra pounds of weight for every

30% increase in daily self30% increase in daily self--weighing during the programweighing during the program–– Participants who selfParticipants who self--weighed at least weekly, had a 27.5 weighed at least weekly, had a 27.5

times greater odds of losing at least 5% of their baseline times greater odds of losing at least 5% of their baseline body weightbody weight

Impact of Impact of ContextContext——Research and PracticeResearch and Practice

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"No health system is yet"No health system is yetmeeting the challenges ofmeeting the challenges of

managing obesity,managing obesity,and no society has developedand no society has developed

an effective strategy toan effective strategy togygyprevent it”prevent it”

The LancetThe Lancet May 13 2006May 13 2006The Lancet, The Lancet, May 13, 2006May 13, 2006However there is progress!!However there is progress!!

Obesity ResourcesObesity ResourcesObesity ResourcesObesity Resources•• www.obesityplus.orgwww.obesityplus.org

b i lib i li•• www.obesityonline.orgwww.obesityonline.org•• www.diabetes.org/home.jspwww.diabetes.org/home.jsp•• www.eatright.orgwww.eatright.orgwww.eatright.orgwww.eatright.org•• www.acsm.orgwww.acsm.org•• http://win.niddk.nih.gov/index.htmhttp://win.niddk.nih.gov/index.htm•• Better Health and You: Tips for Adults Better Health and You: Tips for Adults is a brochure from WIN on is a brochure from WIN on

healthy eating and physical activity. It is part of the series healthy eating and physical activity. It is part of the series Healthy Eating Healthy Eating and Physical Activity Across Your Lifespanand Physical Activity Across Your Lifespan. NIH Publication No. 07. NIH Publication No. 07––4992. 4992.

•• The Practical Guide: Identification Evaluation and Treatment ofThe Practical Guide: Identification Evaluation and Treatment of•• The Practical Guide: Identification, Evaluation, and Treatment of The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults Overweight and Obesity in Adults is an 88is an 88--page guide from NHLBI for page guide from NHLBI for health care providers about helping patients control weight. Includes tools health care providers about helping patients control weight. Includes tools for patients. It is available at for patients. It is available at http://www.nhlbi.nih.gov/guidelines/obesity/practgde.htmhttp://www.nhlbi.nih.gov/guidelines/obesity/practgde.htm . . NIH NIH Publication No. 00Publication No. 00––40844084. .

Obesity ResourcesObesity ResourcesObesity ResourcesObesity Resources

•• www.cdc.gov/nccdphp/dnpa/obesity/ www.cdc.gov/nccdphp/dnpa/obesity/ index.htmindex.htm

•• www.cdc.gov/nchs/nhanes.htmwww.cdc.gov/nchs/nhanes.htm•• www.nih.govwww.nih.gov•• www.niddk.nih.gov/health/nutrit/win.htmwww.niddk.nih.gov/health/nutrit/win.htm•• www.niddk.nih.gov/health/nutrit/nutrit. www.niddk.nih.gov/health/nutrit/nutrit. gg

htmhtm•• www.nlm.nih.gov/medlineplus/obesity.htmlwww.nlm.nih.gov/medlineplus/obesity.htmlg p yg p y

There is light, there is hope!

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