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The Nutrition and Treatment of ObesityThe Nutrition and Treatment of Obesity

Geza BrucknerGeza BrucknerClinical NutritionClinical Nutritiongbruckn@uky.edugbruckn@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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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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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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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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•• 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

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-10

-8

-6

-4

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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

10/29/2008

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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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!