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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 obesity1. Review the nutritional etiology
of obesity1. Review the nutritional etiology of obesity2. Establish
the relevance of diet therapy for 2. Establish the relevance of
diet therapy for obesityobesity3. 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 as the different types of
dietary interventionsinterventions4. Effective diagnosis and
treatment strategies4. Effective diagnosis and treatment
strategies
N t itiN t iti–– NutritionNutrition–– ExerciseExercise
5. Identify other diet therapies for obesity5. Identify other
diet therapies for obesity
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PatientPatientBMIBMI
Obesity Management in an Obesity Management in an Outpatient
Office PracticeOutpatient Office Practice
3737
33332121
4040 3131 2727 2020
29292121
Appropriate Office Environment for Obese PatientsAppropriate
Office Environment for Obese Patients
•• Waiting room chairs without armsWaiting room chairs without
armsS l i i blS l i i bl•• Step stools next to examination
tablesStep stools next to examination tables
•• 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, handouts handouts and treatment
protocolsand treatment protocols
•• Empathetic, Empathetic, respectful respectful and supportive
office staffand supportive office staff
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Initial Office VisitInitial Office Visit•• Include evaluation of
potential obesity related diseases within Include evaluation of
potential obesity related diseases within
history, physical history, physical examination examination and
laboratory testsand laboratory tests•• Obtain weight historyObtain
weight history eatingeating and activity behaviorsand activity
behaviors•• Obtain weight history, Obtain weight history, eating
eating and activity behaviorsand activity behaviors•• Search for
triggering Search for triggering factors factors including
medicationsincluding medications•• Measure weight, height, waist
circumference and calculate Measure weight, height, waist
circumference and calculate
body mass indexbody mass index•• Categorize obesity
classification and health riskCategorize obesity classification and
health risk•• Determine readiness to lose eightDetermine readiness
to lose eight•• Determine readiness to lose weightDetermine
readiness to lose weight•• 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 support
Kushner and Weinsier. Med Clin North Am 2000;84:387.
Key Food TriggersKey Food Triggers
•• BoredomBoredomBoredomBoredom•• Being aloneBeing alone•• Being
in companyBeing in company•• TVTV•• HolidaysHolidays••
HolidaysHolidays•• WeekendsWeekends•• Habitual routine,
etc.Habitual routine, etc.
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Assessing Weight Loss ReadinessAssessing Weight Loss
Readiness
•• Motivation:Motivation:St l lSt l l
Patient seeks weight reductionPatient seeks weight reduction
Free of major life crisesFree of major life crises•• Stress
level:Stress level:•• Psychiatric issues:Psychiatric issues:
•• Time availability:Time availability:
Free of major life crisesFree of major life crises
Free of severe depression, substance Free of severe depression,
substance 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
weeks
P ti t R d ?P ti t R d ?P ti t R d ?P ti t R d ?YESYES NONO
Patient Ready?Patient Ready?Patient Ready?Patient Ready?
Prevent weight gain Prevent weight gain and explore barriers to
and explore barriers to
weight reductionweight reduction
Initiate weight loss Initiate weight loss therapytherapy
FactoidsFactoids• Obesity is a chronic disease
• Modest weight loss (5% -10% of body weight) can g ( y g )have
considerable medical benefits
• Lifestyle change (diet and physical activity) is the
cornerstone of therapy
• Pharmacotherapy can be useful in properly selected py p p
ypatients
• Bariatric surgery is the most effective therapy for type III
Obesity
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StrokeStroke
DiabetesDiabetes
Health Health Consequences Consequences of Obesityof Obesity
Liver DiseaseLiver Disease
Colon CancerColon CancerHeart DiseaseHeart Disease
Osteoarthritis
http://www.24kt.us/Fatbig.jpg
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Health Consequences of ObesityHealth Consequences of Obesity
MentalMentaldepressiondepression
MechanicalMechanical-- osteoarthritisosteoarthritis
MetabolicMetabolic-- diabetesdiabetes-- depressiondepression
-- anxietyanxiety-- personality personality
disorderdisorder-- self esteemself esteem-- etc.etc.
osteoarthritisosteoarthritis--obstructive obstructive sleep
apneasleep apnea
-- reflux diseasereflux disease-- urinary incontinenceurinary
incontinence-- intertrigointertrigo-- etc.etc.
diabetesdiabetes-- dyslipidemiadyslipidemia-- fatty liverfatty
liver-- hypertensionhypertension-- cancercancer-- PCOSPCOS-- gall
bladdergall bladder-- infertilityinfertility-- etc.etc.
Cause of Obesity: ImbalanceCause of Obesity: Imbalance
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BAGELBAGEL20 Years Ago Todayy
140 calories 3-inch diameter
How many calories are in this bagel?
BAGELBAGEL20 Years Ago Todayy
140 calories 3-inch diameter
Calorie Difference: 210 calories
350 calories6-inch diameter
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Maintaining a Healthy Weight is a Balancing ActCalories In =
Calories Out
How long will you have to rake leaves in order to 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.*
*Based on 130-pound person
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CHEESEBURGER20 Years Ago Today
Calorie Difference: 257 calories
590 calories333 calories
Calories In = Calories Out
If you lift weights for 1 hour and 30 minutes,you will burn
approximately 257 calories.*
*Based on 130-pound person
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20 Years Ago Today
SPAGHETTI AND MEATBALLSg y
Calorie Difference: 525 calories
1,025 calories2 cups of pasta with sauce and 3 large
meatballs
500 calories1 cup spaghetti with sauce and 3 small meatballs
Calories In = Calories Out
*Based on 130-pound person
If you houseclean for 2 hours and 35 minutes, you will burn
approximately 525 calories.*
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FRENCH FRIESFRENCH FRIES20 Years Ago Today
610 Calories6.9 ounces
Calorie Difference: 400 Calories
210 Calories2.4 ounces
Calories In = Calories Out
*Based on 160-pound person
If you walk leisurely for 1 hour and 10 minutesyou will burn
approximately 400 calories.*
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TURKEY SANDWICHTURKEY SANDWICH20 Years Ago Todayg y
Calorie Difference: 500 calories
820 calories320 calories
Calories In = Calories Out
*Based on 160-pound person
If you ride a bike for 1 hour and 25 minutes,you will burn
approximately 500 calories.*
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Factors Factors Contributing toContributing toGradual Weight
GainGradual Weight Gain
• Most individuals gradually gain weight over a long period of
timetime– Often without realizing they have changed their
behaviors
• These changes could be very small– An excess of only 10 Kcal/d
could result in a weight gain of ~1 lb/yr
~10 lbs in 10 years
• The modern environment has taken successful body weight• The
modern environment has taken successful body-weight 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
gaining weight. (Obesity Reviews 2002;3, 69–74.)
Obesity Class BMI kg/m2
U d i ht
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Obesity TreatmentObesity Treatment
PharmacotherapyPharmacotherapy
SurgerySurgery
Obesity IIObesity II
Obesity IIIObesity III
Lifestyle ModificationLifestyle Modification
pypy
OverweightOverweight
Obesity IObesity I
Obesity Treatment: Not Simple!Obesity Treatment: Not Simple!
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Selected Medications That Can Selected Medications That Can
Cause Weight GainCause Weight Gain
•• Psychotropic medicationsPsychotropic medications Diabetes
medicationsDiabetes medicationsI liI li–– TricyclicTricyclic
antidepressantsantidepressants
–– Monoamine Monoamine oxidaseoxidaseinhibitorsinhibitors
–– Specific SSRIsSpecific SSRIs
–– Atypical antipsychoticsAtypical antipsychotics
LithiumLithium
–– InsulinInsulin–– SulfonylureasSulfonylureas––
ThiazolidinedionesThiazolidinediones
Highly active Highly active antiretroviral therapyantiretroviral
therapy
–– LithiumLithium
–– Specific anticonvulsantsSpecific anticonvulsants
•• --adrenergic receptor adrenergic receptor
blockersblockers
TamoxifenTamoxifen
Steroid hormonesSteroid hormones––
GlucocorticoidsGlucocorticoids–– ProgestationalProgestational
steroidssteroids
How Important are Genetic Factors How Important are Genetic
Factors in the Development of Obesity?in the Development of
Obesity?
Harris AM et al. Obesity 2006;14:690-695
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Hurdles of Weight LossHurdles of Weight Loss•• Body tries to
maintain fat stores by regulating theBody tries to maintain fat
stores by regulating the
amount of food and calories amount of food and calories
consumedconsumed•• Research with animals and humans has found that
aResearch with animals and humans has found that a
person has a programmed “set point” person has a programmed “set
point” weightweight•• The existence of this set point helps to
explain whyThe existence of this set point helps to explain why
most diets do not most diets do not workwork•• In addition,
their set point is now set at a higher In addition, their set point
is now set at a higher levellevel
ki i diffi l lki i diffi l l i hi hmaking it even more difficult
to lose making it even more difficult to lose weightweight••
“Ratchet effect” and “yo“Ratchet effect” and “yo--yo dietingyo
dieting””•• The key to overcoming the fat cell’s set point
appearsThe key to overcoming the fat cell’s set point appears
to be increasing the sensitivity of the fat cells to to be
increasing the sensitivity of the fat cells to insulininsulin
ControlControlof of Energy Energy
MetabolismMetabolismMetabolismMetabolism
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The The Status Status of the HPA of the HPA Axis Axis in in
Relation Relation to to Visceral ObesityVisceral Obesity, ,
GlucoseGlucose, , Insulin Insulin and and LipidsLipids
Rosmond Med Sci Monit, 2003; 9(2): RA35-39
Rosmond: Med Sci Monit, 2003; 9(2): RA35-39
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Reactivity Reactivity Profiles Profiles of of High High and and
Low Low Reactors During Stress SessionReactors During Stress
Session
Epel et al. Psychoneuroendocrinology 26 (2001) 37–49
Raw Raw Mean Calories Consumed byMean Calories Consumed
byReactivity Group Reactivity Group on on Stress andStress and
Control DaysControl Days
Epel et al. Psychosomatic Medicine 62:623632 (2000)
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FactoidsFactoids•• Healthy, Healthy, active living is important
at any active living is important at any
weightweight•• M i tM i t f h lthf h lth l il i di t ddi t d••
Maintenance Maintenance of healthy of healthy eucaloriceucaloric
diets anddiets and
physical physical activity are essential to activity are
essential to prevent prevent weight weight gaingain
•• Once Once established, obesity is a chronic
diseaseestablished, obesity is a chronic diseaseandand requires
longrequires long term management andterm management andand and
requires longrequires long--term management and term management and
treatmenttreatment
•• Weight Weight alone is a poor indicator of body fat oralone
is a poor indicator of body fat orrelated related health
riskshealth risks
Systematic Review of Weight Loss StudiesSystematic Review of
Weight Loss StudiesAverage 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%)
-10
-8
-6
-4
-2
0
2
ht L
oss
(kg)
-20
-18
-16
-14
-12
1 2 3 4 5 6
Wei
gh
Exercise AloneDiet + ExerciseDiet A loneM eal
ReplacementsVLCDOrlistatSibutramineAdvice Alone
6-mo 12-mo 24-mo 36-mo 48-mo
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Popular Diets Popular Diets -- CompositionComposition
Kcal Kcal Kcal Kcal Kcal Kcal Kcal Sat Kcal Sat Chol Chol Fiber
Fiber DietDietProgram Program
CHO CHO (%) (%)
Pro Pro (%) (%)
Fat Fat (%) (%)
Fat Fat (%) (%)
(m(mg) g)
(g(gm) m)
Atkins Atkins 55 3535 5959 2626 924924 44“Protein “Protein
Power” Power” 88 3535 5353 1919 657657 1111“Sugar “Sugar
Busters” Busters” 4040 2828 3232 99 280280 2424“The “The
Zone” Zone” 3232 2828 3232 77 264264 1818
Ornish Ornish 7474 1818 77 22 3030 4949
Evidence Model for Treatment of Evidence Model for Treatment of
Overweight and ObesityOverweight and Obesity
Cardiovascular Mortality and Morbidity
Noncardiovascular Mortality and MorbidityOverweight
Individual
Cardiovascular Disease
Dyslipidemia Glucose Intolerance
High Blood Pressure
TreatKcal Out( ( Kcal In ))
Abdominal Fat Weight Fitness
Assess
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Treatment AlgorithmPatient Encounter
Hx of 25 BMI?
No
Yes
1
2
3 BMImeasured in past
2 years?
• Measure weight, height, and waistcircumference
• Calculate BMIClinician and patientdevise goals andtreatment
strategyfor weight loss andrisk factor control
Assess risk factors
14
15 13
12
4 6
5 7
8
9
Yes
No
Yes
No
Hx BMI 25?
No
Yes
Yes
No
Doespatient want tolose weight?
Yes Progress being made/goal achieved?
BMI 25 ORwaist circumference
> 88 cm (F)> 102 cm (M)
BMI30 OR
{[BMI 25 to 29.9 OR waist circumference
>88 cm (F) >102 cm (M)]AND 2 risk
factors}
Examination
Brief reinforcement/ educate on weight management
Periodic weightcheck
Advise to maintainweight/addressother risk factors
Assess reasons forfailure to lose weight
Maintenance counseling: Dietary therapyBehavior therapyPhysical
activity:
Treatment11 1016
No
Talking With Patients About Talking With Patients About Weight
LossWeight Loss: Tips : Tips for Primary for Primary Care
ProfessionalsCare Professionals•• Patients who were counseled in a
primary care setting Patients who were counseled in a primary care
setting
about the benefits of healthy eating and physical about the
benefits of healthy eating and physical activity lost weight,
consumed less activity lost weight, consumed less fat fat and
exercised and exercised more than patients who did not receive more
than patients who did not receive counselingcounseling
•• 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 behavior changechange
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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 careUnfortunately, the
majority of primary careUnfortunately, 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 about about weightweight
•• Most people who are overweight or obese Most people who are
overweight or obese want assistance in setting and achievingwant
assistance in setting and achievingwant assistance in setting and
achieving want assistance in setting and achieving
weightweight--loss loss goals goals but may hesitate to broach but
may hesitate to broach the topic during office the topic during
office visitsvisits
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 weight, reduce their health weight, reduce their
health risks risks and make and make them feel them feel better
better but assure patients that your but assure patients that your
interest in their health is not dependent on their interest in
their health is not dependent on their
i l ii l i i hi hsuccess in losing success in losing
weightweight
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What What Do Patients Want Do Patients Want from from Health
Health Care Professionals Regarding WeightCare Professionals
Regarding Weight??•• TalkTalkTalkTalk
–– Before Before starting a conversation about weight control
with starting a conversation about weight control with your
patients, allow them to discuss other issues that may your
patients, allow them to discuss other issues that may be affecting
their physical or emotional be affecting their physical or
emotional wellwell--beingbeing
•• NonNon--offensive offensive termsterms–– Patients Patients
prefer the terms “weight” or “excess prefer the terms “weight” or
“excess
i ht”i ht” d di lik th t “ b it ” “f t ”d di lik th t “ b it ”
“f t ”weight” weight” and dislike the terms “obesity,” “fatness,”
and dislike the terms “obesity,” “fatness,” and “excess and “excess
fat”fat”
–– You You may wish to ask your patients what terms they may
wish to ask your patients what terms they prefer when discussing
prefer when discussing weightweight
What What Do Patients Want Do Patients Want from from Health
Health Care Professionals Regarding WeightCare Professionals
Regarding Weight??
•• Advice they can Advice they can useuse–– Realistic Realistic
weight weight goalsgoals–– Specific Specific type of type of
exerciseexercise–– Weight Weight loss products and servicesloss
products and services
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Which Which Patients Might Benefit Patients Might Benefit from a
from a Discussion Discussion about about Weight?Weight?Approach
Approach the subject of weight loss if your patient the subject of
weight loss if your patient pppp j g y pj g y phashas–– A A body
mass index (BMI)* of 30 or body mass index (BMI)* of 30 or
aboveabove–– A A BMI between 25 and 30 and two or more weightBMI
between 25 and 30 and two or more weight--related related
health health problems problems such as a family history of
coronary heart such as a family history of coronary heart disease
or disease or diabetesdiabetesAA i t t 35 i h ( ) 40 i hi t t 35 i
h ( ) 40 i h–– A A waist measurement over 35 inches (women) or 40
inches waist measurement over 35 inches (women) or 40 inches
(men)(men)——even if BMI is less than 25even if BMI is less than
25——and two or more and two or more weightweight--related health
related health problems problems such as a family history of such
as a family history of coronary heart disease or coronary heart
disease or diabetesdiabetes
Tips for Talking About Weight ControlTips for Talking About
Weight Control
•• Address your patient’s chief health concerns orAddress your
patient’s chief health concerns or•• Address your patient’s chief
health concerns orAddress your patient’s chief health concerns
orAddress your patient s chief health concerns or Address your
patient s chief health concerns or complaints complaints first
first independent of independent of weightweight
•• 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
P ib h lth ti d h i l ti it
Address your patient s chief health concerns or Address your
patient s chief health concerns or complaints complaints first
first independent of independent of weightweight
•• 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
P ib h lth ti d h i l ti it• Prescribe healthy eating and
physical activity behaviors
• Follow up
• Prescribe healthy eating and physical activity behaviors
• Follow up
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Dietary Approaches in the Management of Overweight and
Obesity
Dietary Approaches in the Management of Overweight and
Obesity
• Low-fat diets• Low-energy diets• Fixed energy deficit
– 2.5 MJ (600 kcal) energy deficit from calculated energy
requirements
• Low-fat diets• Low-energy diets• Fixed energy deficit
– 2.5 MJ (600 kcal) energy deficit from calculated energy
requirementsenergy requirements
• Meal replacements• Very-low-energy diets
energy requirements• Meal replacements• Very-low-energy
diets
Weight Maintenance Skills are Distinct from Those Required to
Achieve Weight Loss
Weight Maintenance Skills are Distinct from Those Required to
Achieve Weight Loss
• The skills required for maintenance phase is enabling
individuals to remain motivated without the powerful reinforcement
of losing weight
• The skills required for maintenance phase is enabling
individuals to remain motivated without the powerful reinforcement
of losing weight
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The National Weight Control Registry is the Largest Study of
Individuals Successful at Long-term Weight Maintenance.
The National Weight Control Registry is the Largest Study of
Individuals Successful at Long-term Weight Maintenance.
•• They report that the successful maintainers have the
following They report that the successful maintainers have the
following •• They report that the successful maintainers have the
following They report that the successful maintainers have the
following
www.nwcr.ws
y p gy p ghabitshabits–– 78% eat breakfast every 78% eat
breakfast every day day –– 75% weigh them self at least once a 75%
weigh them self at least once a week week –– 62% watch less than 10
hours of TV per 62% watch less than 10 hours of TV per weekweek––
90% exercise, on average, about 1 hour per day90% exercise, on
average, about 1 hour per day
y p gy p ghabitshabits–– 78% eat breakfast every 78% eat
breakfast every day day –– 75% weigh them self at least once a 75%
weigh them self at least once a week week –– 62% watch less than 10
hours of TV per 62% watch less than 10 hours of TV per weekweek––
90% exercise, on average, about 1 hour per day90% exercise, on
average, about 1 hour per day–– limiting fast food intakelimiting
fast food intake–– accepting realistic weigh goalsaccepting
realistic weigh goals–– recognizing that weight control is not
‘painless’ but recognizing that weight control is not ‘painless’
but
requires ongoing commitmentrequires ongoing commitment
–– limiting fast food intakelimiting fast food intake––
accepting realistic weigh goalsaccepting realistic weigh goals––
recognizing that weight control is not ‘painless’ but recognizing
that weight control is not ‘painless’ but
requires ongoing commitmentrequires ongoing commitment
LowLow--Calorie Step I DietCalorie Step I DietLowLow--Calorie
Step I DietCalorie Step I Diet
NutrientNutrient Recommended IntakeRecommended
IntakeNutrientNutrient Recommended IntakeRecommended
IntakeNutrientNutrient Recommended IntakeRecommended Intake
CaloriesCalories 500500--1,000 1,000 kcal/day reduction kcal/day
reduction
Total FatTotal Fat 30 30 % or % or less of total caloriesless of
total calories
SFASFA 88--10% 10% of total caloriesof total calories
MUFA MUFA Up to Up to 15% of 15% of total caloriestotal
calories
NutrientNutrient Recommended IntakeRecommended Intake
CaloriesCalories 500500--1,000 1,000 kcal/day reduction kcal/day
reduction
Total FatTotal Fat 30 30 % or % or less of total caloriesless of
total calories
SFASFA 88--10% 10% of total caloriesof total calories
MUFA MUFA Up to Up to 15% of 15% of total caloriestotal
caloriespp
PUFAPUFA Up to Up to 10% of 10% of total caloriestotal
calories
CholesterolCholesterol < 300 < 300 mg/daymg/day
pp
PUFAPUFA Up to Up to 10% of 10% of total caloriestotal
calories
CholesterolCholesterol < 300 < 300 mg/daymg/day
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LowLow--Calorie Step I Diet Calorie Step I Diet
((cont’dcont’d))LowLow--Calorie Step I Diet Calorie Step I Diet
((cont’dcont’d))
NutrientNutrient Recommended IntakeRecommended
IntakeNutrientNutrient Recommended IntakeRecommended Intake
ProteinProtein ~ ~ 15% of 15% of total caloriestotal
calories
CarbohydrateCarbohydrate 55% or 55% or more of total
caloriesmore of total calories
Sodium ChlorideSodium Chloride No more than 100 No more than 100
mmolmmol/day (~ 2.4 g /day (~ 2.4 g of sodium or ~ 6 g of sodium of
sodium or ~ 6 g of sodium chloride)chloride)
ProteinProtein ~ ~ 15% of 15% of total caloriestotal
calories
CarbohydrateCarbohydrate 55% or 55% or more of total
caloriesmore of total calories
Sodium ChlorideSodium Chloride No more than 100 No more than 100
mmolmmol/day (~ 2.4 g /day (~ 2.4 g of sodium or ~ 6 g of sodium of
sodium or ~ 6 g of sodium chloride)chloride)))
CalciumCalcium 1,0001,000--1,500 1,500 mgmg
FiberFiber 2020--30 30 gg
))
CalciumCalcium 1,0001,000--1,500 1,500 mgmg
FiberFiber 2020--30 30 gg
Physical ActivityRecommended as part of a comprehensive weight
loss therapy and maintenance program because it:
• Modestly contributes to weight lossEvidence Category A.
• May decrease abdominal fat Evidence Category B.g y
• Increases cardiorespiratory fitness Evidence Category A.
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Increase Physical Activity
• Most important in preventing weight regain • Health benefits
independent of weight loss• Health benefits independent of weight
loss• Start slowly and increase gradually
— Can be single session or intermittent— Start with walking 30
minutes 3 days/week
I t 45 i t 5 d / k— Increase to 45 minutes 5 or more days/week—
Encourage increased “lifestyle” activities
10,000 Steps10,000 Steps®® ResultsResults
•• 25% lose 4 lbs of25% lose 4 lbs of•• 25% lose 4 lbs of25%
lose 4 lbs of11500 100%St ep T racking 21% increase fro m D ay 1
25% lose 4 lbs of 25% lose 4 lbs of weight or moreweight or
more
•• 93% indicate they 93% indicate they would refer the would
refer the 10,000 Steps10,000 Steps®®program to a friendprogram to a
friend
25% lose 4 lbs of 25% lose 4 lbs of weight or moreweight or
more
•• 93% indicate they 93% indicate they would refer the would
refer the 10,000 Steps10,000 Steps®®program to a friendprogram to a
friend7500
8000
8500
9000
9500
10000
10500
11000
1 6 11 16 21 26 31 36 41 46 51 56
Ped
omet
er S
teps
(mea
n)
30%
40%
50%
60%
70%
80%
90%
Recorded S
teps (%)
St ep A ct ivit y
fro m D ay 1
0%0
VanWormer, J., et al. Diab Spectrum
2006;19(4):197-200.Schneider, et al. Am J Health Promot
2006;21(2):85-89.
•• 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
1 6 11 16 21 26 31 36 41 46 51 56
Program Day
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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 Individuals
HDL
Baseline 20 Weeks 36 Weeks
•• Single group, repeated Single group, repeated •• Single
group, repeated Single group, repeated * +3 mg/dl
Fat Mass
FFM
Wcirc
Hip Circ
HDLg g p pg g p p
measures experimental designmeasures experimental design••
Community recruitmentCommunity recruitment•• N=56N=56•• Number of
steps:Number of steps:
–– Baseline = 5,123Baseline = 5,123–– 20 weeks = 9,324 * 20
weeks = 9,324 * –– 36 weeks = 9,117 *36 weeks = 9,117 *
N h i di tN h i di t
g g p pg g p pmeasures experimental designmeasures experimental
design
•• Community recruitmentCommunity recruitment•• N=56N=56••
Number of steps:Number of steps:
–– Baseline = 5,123Baseline = 5,123–– 20 weeks = 9,324 * 20
weeks = 9,324 * –– 36 weeks = 9,117 *36 weeks = 9,117 *
N h i di tN h i di t
+3 mg/dl
* -1.9 cm
* -1.8 cm
* 0.5 kg
* -2.7 kg
0 25 50 75 100 125
Weight
BMI
BF% •• No changes in dietNo changes in diet
* = statistically significant improvement* = statistically
significant improvement
•• No changes in dietNo changes in diet
* = statistically significant improvement* = statistically
significant improvement
* -1.9%
* -0.8 kg/m2
* -2.4 kg
Schneider, et al. Am J Health Promot 2006;21(2):85-89.
Behavior Therapy
The routine use of behavior therapy strategies toThe 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.
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30
Behavior Therapy (continued)Implementation of strategies, based
on learning principles, that provide tools for overcoming barriers
to compliance with diet or physical activity changes:
• Self-monitoring• Stress management• Stimulus control•
Problem-solving• Contingency management• Cognitive restructuring•
Social support
Self-Monitoring
Keep records of:
• Amount and types of foods eaten
• Frequency, intensity, and type of physical activity
• Time, place, and feelings
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31
Stress Management
Defuse situations that lead to overeating:
• Coping strategies
• Meditation
R l ti t h i• Relaxation techniques
Stimulus Control
Behavior change techniques:
• Learn to shop for healthy foods.
• Keep high-calorie foods out of the home.
• Limit the times and places of eating• Limit the times and
places of eating.
-
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32
Cognitive RestructuringRational thoughts designed to replace
negativethoughts:thoughts:Instead of. . .
“I blew my diet this morning by eating that doughnut.”
UseUse. . . “Well, I ate the doughnut, but I can still eat in
a
healthy manner the rest of the day.”
Social Support
Maintain motivation and positive i freinforcement:
• Family
• Friends
• Colleagues
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33
•• WeighWeigh--ByBy--Day Trial Day Trial –– an effectiveness
trialan effectiveness trial–– HomeHome based scale connected via
telephone line to healthbased scale connected via telephone line to
health
Optimizing Practice through ResearchOptimizing Practice through
Research
–– 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 weight weighing a significant predictor for weight
lossloss
–– 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
weighed at least weekly weekly had a 27.5 had a 27.5 times greater
odds of losing at least 5% of their baseline bodytimes greater odds
of losing at least 5% of their baseline bodytimes greater odds of
losing at least 5% of their baseline body times greater odds of
losing at least 5% of their baseline body weightweight
Impact of Impact of ContextContext——Research and
PracticeResearch and Practice
-2
0Baseline Post-Course ~12 Months
)
-10
-8
-6
-4
Wei
ght L
oss (
poun
ds)
RCT; no follow-up
RCT; daily weigh-in with feedback
-14
-12
Weigh-To-Be Trial Weigh-By-Day Trial Worksite-Based
Experience
Real-world with worksite“environmental” support
-
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34
"No health system is yet"No health system is yetmeeting the
challenges ofmeeting the challenges ofmeeting the challenges
ofmeeting the challenges of
managing managing obesityobesityand no society has developedand
no society has developed
an effective strategy toan effective strategy toprevent
it”prevent it”
The Lancet, The Lancet, May 13, 2006May 13, 2006However there is
progress!!However there is progress!!
Obesity ResourcesObesity Resources••
www.obesityplus.orgwww.obesityplus.org••
www.obesityonline.orgwww.obesityonline.org••
www.diabetes.org/home.jspwww.diabetes.org/home.jspg j pg j p••
www.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 Better Health and You: You: Tips for Tips for
AdultsAdults
–– A A brochure from WIN on healthy eating and physical brochure
from WIN on healthy eating and physical activityactivity–– Part
Part of the series of the series Healthy Eating and Physical
Activity Across Your LifespanHealthy Eating and Physical Activity
Across Your Lifespan. NIH . NIH
Publication No. 07Publication No. 07––49924992..Publication No.
07Publication No. 07 49924992..•• The Practical Guide:
Identification, The Practical Guide: Identification, Evaluation
Evaluation and Treatment of and Treatment of
Overweight and Obesity in Overweight and Obesity in
AdultsAdults–– An An 8888--page guide from NHLBI for health care
providers about helping patients control page guide from NHLBI for
health care providers about helping patients control
weightweight–– Includes Includes tools for tools for
patientspatients–– Available Available at at
http://www.nhlbi.nih.gov/guidelines/obesity/practgde.htmhttp://www.nhlbi.nih.gov/guidelines/obesity/practgde.htm
. . NIH Publication NIH Publication
No. No. 0000––40844084
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35
Obesity ResourcesObesity Resources
•• www.cdc.gov/nccdphp/dnpa/obesity/
index.htmwww.cdc.gov/nccdphp/dnpa/obesity/
index.htmwww.cdc.gov/nccdphp/dnpa/obesity/
index.htmwww.cdc.gov/nccdphp/dnpa/obesity/ index.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/nutritwww niddk nih
gov/health/nutrit/nutrit
htmhtmwww.niddk.nih.gov/health/nutrit/nutrit.
www.niddk.nih.gov/health/nutrit/nutrit. htmhtm••
www.nlm.nih.gov/medlineplus/obesity.htmlwww.nlm.nih.gov/medlineplus/obesity.html
There is light there is hope!
ThanksThanks
g p
Thanks!