Motivational Motivational Interviewing for Interviewing for Weight Loss & Weight Loss &

ExerciseExerciseFrank J. Domino, M.D.Frank J. Domino, M.D.

ProfessorProfessor

Frank.domino@umassmemoriFrank.domino@umassmemorial.orgal.org

By the end of this session, the By the end of this session, the learner will:learner will:

Understand the basic components of Understand the basic components of Motivational Interviewing Motivational Interviewing

Learn how to apply Motivational Learn how to apply Motivational Interviewing to weight loss and exerciseInterviewing to weight loss and exercise

Review the current literature on what is Review the current literature on what is effective in helping patients lose weighteffective in helping patients lose weight

Consider Brianne….Consider Brianne…. 26 year old female, G0P0; Tobacco use x 26 year old female, G0P0; Tobacco use x

5 yrs5 yrs Ht: 65 inches; Weight: 285 lbsHt: 65 inches; Weight: 285 lbs BMI: 47.4BMI: 47.4

Normal: Normal: 20-2520-25 Overweight: Overweight: 25-29.925-29.9 Obese:Obese: >/= 30>/= 30

““I’ve tried everything & can’t lose weight”I’ve tried everything & can’t lose weight” You think: “I’ve tried everything too!!!!”You think: “I’ve tried everything too!!!!”

Motivational InterviewingMotivational Interviewing

A style of talking with people constructively A style of talking with people constructively about reducing their health risks and about reducing their health risks and changing their behavior.changing their behavior.

Designed to Enhance the Designed to Enhance the patient’s own patient’s own motivation motivation to change using strategies to change using strategies that are empathic and non-confrontationalthat are empathic and non-confrontational..

Behavioral Problems Behavioral Problems

Addressed by MIAddressed by MI

• LifestyleLifestyle

• Chemical dependencyChemical dependency

• Non-adherence to treatmentNon-adherence to treatment

• Miscellaneous risky or unsafe Miscellaneous risky or unsafe behaviorsbehaviors

Carefully defined and rigorously studied Carefully defined and rigorously studied psychosocial substance abuse treatments.psychosocial substance abuse treatments.

Is a Is a relativelyrelatively brief intervention. brief intervention.

Has wide application to behavioral domainsHas wide application to behavioral domains

Compatible with many different approaches.Compatible with many different approaches.

Reasons for MI’s Reasons for MI’s PopularityPopularity

Positively impacts treatment and Positively impacts treatment and retention.retention.

Improved Improved weight controlweight control program program behavioral adherence, glucose control and behavioral adherence, glucose control and weight loss outcomes among Type 2 weight loss outcomes among Type 2 diabetic patients. diabetic patients. Smith et al. Diabetes Care; 1997;20:52-4; Harland et al., Brit Med J. 1999;319:828-31.

Increased Increased physical activityphysical activity and exercise and exercise energy expenditure among cardiac energy expenditure among cardiac rehabilitation patientsrehabilitation patients

Scales R, Miller JH. Current Sports Medicine Reports. 2003;2:166-72.

Bowen

Efficacy of MI in Obesity & Efficacy of MI in Obesity & ExerciseExercise

Efficacy of MI in HabitsEfficacy of MI in Habits

Increased fruit & vegetable consumptionIncreased fruit & vegetable consumption

Bowen et al. 2002; Resnicow et al. Am J Pub Health. 2001;91:1686-93;

Resnicow et al. Health Psych. 2005;24:339-48;

Motivational interviewing was Motivational interviewing was 5 times 5 times as as effective as brief advice for achieving effective as brief advice for achieving sustained sustained smoking cessationsmoking cessation..

Soria, R.; A randomised controlled trial of motivational interviewing for smoking cessation, Br.J.Gen.Pract., 2006, 56, 531, 768-774

• Helped patients change Helped patients change problematic problematic behaviors related to hypertensionbehaviors related to hypertension..Woollard J et al. Clin Exp Pharm Phys. 1995;23:466-8.

Motivational InterviewingMotivational Interviewing

1.1. Establish rapport & Elicit Establish rapport & Elicit Change Change TalkTalk: OARS: OARS

Open questionsOpen questions AffirmationsAffirmations ReflectionsReflections SummarizeSummarize

2.2. Develop Discrepancy to Facilitate Develop Discrepancy to Facilitate Change TalkChange Talk using Rulers using Rulers

3.3. Offer adviceOffer advice4.4. End interview with a summary & End interview with a summary &

planplan

How does MI WorkHow does MI Work

AMBIVALENCE is the key issue to be AMBIVALENCE is the key issue to be

resolved for change to occur.resolved for change to occur. People change when they hear People change when they hear their own their own

discussion of their ambivalence.discussion of their ambivalence. This discussion is called “This discussion is called “change talkchange talk” ” Getting patients to engage in “change Getting patients to engage in “change

talk” is critical element of the MI process.talk” is critical element of the MI process.

*Glovsky and Rose, 2008*Glovsky and Rose, 2008

Change TalkChange Talk

Desire- “I really want to lose weight.”Desire- “I really want to lose weight.” Ability- “I have done it before.”Ability- “I have done it before.” Reason- “My kids really want me to.”Reason- “My kids really want me to.” Need- “I can’t live like this.”Need- “I can’t live like this.” Commitment- “I can get this under Commitment- “I can get this under

control.”control.”

GOAL: Have Patient Express Reason for GOAL: Have Patient Express Reason for ChangeChange

Motivational Interviewing (MI) Rules Motivational Interviewing (MI) Rules (EARS)(EARS)

Express Empathy:Express Empathy: ““I know it must be hard…”I know it must be hard…”

Avoid ArgumentationAvoid Argumentation Follow patient’s lead (even if incorrect)Follow patient’s lead (even if incorrect)

Roll with ResistanceRoll with Resistance AmbivalenceAmbivalence is necessary to motivate is necessary to motivate

changechange Support Self Efficacy:Support Self Efficacy:

Person is responsible for the changePerson is responsible for the change

Brief MI in 5 StepsBrief MI in 5 Steps

Establish rapport & Elicit Change Talk: Establish rapport & Elicit Change Talk: OARSOARSOpen questionsOpen questionsAffirmationsAffirmationsReflectionsReflectionsSummarizeSummarize

Develop Discrepancy to Facilitate change Develop Discrepancy to Facilitate change talk using Rulerstalk using Rulers

Offer adviceOffer advice End the interview with a summary and planEnd the interview with a summary and plan

“Would you like to lose weight?”

Vs.

How do you feel about your weight?

OARSOpen-Ended Questions

“How much ice cream do you eat?”

Vs

“Please tell me more about what you eat for dessert?”

Open-Ended Questions

OOAARSRSAffirmationsAffirmations

Support the patientSupport the patientConvey respect & Convey respect & understandingunderstanding

Help patients reveal Help patients reveal less less positive positive aspects of aspects of themselvesthemselves

Affirmations Affirmations (continued)(continued)

““Dealing with weight issues is Dealing with weight issues is difficult”difficult”

““You have worked so hard.”You have worked so hard.”““I can understand why eating I can understand why eating feels good to you.” feels good to you.”

OAOARRSSReflective ListeningReflective Listening

Goal: to facilitate further patient Goal: to facilitate further patient commentcomment

Method: Method: RestateRestate patient’s words in non patient’s words in non judgmental mannerjudgmental manner

Speak a statement, not a question:Speak a statement, not a question:

“You eat an “You eat an entire bagentire bag of chips at once? of chips at once?

Vs.Vs.

““sometimes you can eat a bag of chips”sometimes you can eat a bag of chips”

Reflective Listening

“My boyfriend gets really angry when I eat French fries.”

You respond:

“So, he gets mad when you eat French Fries”

Reflective Listening

“I can’t control myself if I am stressed out”

You Say:

“It must be hard to control yourself when you are worried”

OAROARSSSummarizeSummarize

Goal: Designate transition pointGoal: Designate transition point

““What you’ve said is important.”What you’ve said is important.”““This is what I hear you saying”This is what I hear you saying”““We covered that well. Now let's We covered that well. Now let's

talk about..”talk about..”

Brief MI in 5 StepsBrief MI in 5 Steps1.1. Establish rapport & Elicit Change Establish rapport & Elicit Change

Talk: OARSTalk: OARS Open questionsOpen questions

AffirmationsAffirmations ReflectionsReflections SummarizeSummarize

2.2. Develop Discrepancy to Develop Discrepancy to Facilitate change talk using Facilitate change talk using

RulersRulers3.3. Offer adviceOffer advice

4.4. End the interview with a summary End the interview with a summary and planand plan

2. dIsCrepancy 2. dIsCrepancy RulersRulers

Discrepancy:Discrepancy:

On a scale of 1 – 10, how On a scale of 1 – 10, how IMPORTANTIMPORTANT is it for you to lose is it for you to lose weight?weight?

On a scale of 1 – 10, how On a scale of 1 – 10, how CONFIDENTCONFIDENT are your ability to are your ability to lose weight?lose weight?

Discrepancy RulersDiscrepancy RulersImportantImportant

11 55 1010

ConfidentConfident

11 55 1010

2. Discrepancy Rulers2. Discrepancy Rulers

Discrepancy:Discrepancy:

On a scale of 1 – 10, how IMPORTANT is it On a scale of 1 – 10, how IMPORTANT is it for you to lose weight? for you to lose weight? “8”“8”

““GREAT! sounds like losing weight is GREAT! sounds like losing weight is important to you”important to you”

On a scale of 1 – 10, how CONFIDENT are On a scale of 1 – 10, how CONFIDENT are you in your ability to lose weight? you in your ability to lose weight? “3”“3”

2. Discrepancy Ruler2. Discrepancy Ruler

AmbivalenceAmbivalence: 8 vs 3: 8 vs 3

““Really.., I thought you would Really.., I thought you would have said 1 or 2 (a number have said 1 or 2 (a number less). What would it take you less). What would it take you to go up 1-2 points?to go up 1-2 points?

““Well, I guess I could get all of Well, I guess I could get all of the bad foods out of the the bad foods out of the house”house”

Brief MI in 5 StepsBrief MI in 5 Steps1.1. Establish rapport & Initiate Establish rapport & Initiate

Discussion: OARSDiscussion: OARS Open questionsOpen questions

AffirmationsAffirmations ReflectionsReflections SummarizeSummarize

2.2. Develop Discrepancy to Facilitate Develop Discrepancy to Facilitate change talk using Rulerschange talk using Rulers

3.3. Offer adviceOffer advice4.4. End the interview with a End the interview with a

summary and plansummary and plan

3.3. AdviceAdvice

AdviceAdvice::Very few specificsVery few specifics““top down” statements from their top down” statements from their

doctors doctors Have patient decide what they Have patient decide what they want to do, then advise.want to do, then advise.

““Well, I could get all the tempting Well, I could get all the tempting snacks out of the house & not buy any snacks out of the house & not buy any more…”more…”

4. Action Plan4. Action PlanAction PlanAction Plan

Based upon patient’s suggestionBased upon patient’s suggestionProvide Provide optionsoptions for patient for patientBe open to whatever they Be open to whatever they suggestsuggest

ALWAYS schedule Follow up ALWAYS schedule Follow up with agreed upon with agreed upon GoalGoal

3/4: Advice & Action Plan3/4: Advice & Action Plan

““Terrific! Getting snacks out of the house is a Terrific! Getting snacks out of the house is a great start. But, what will you do when you great start. But, what will you do when you get the urge to snack? Do you know what get the urge to snack? Do you know what snacks to have in the house that are healthy?”snacks to have in the house that are healthy?”

““Kind of…”Kind of…” “ “Well, we have a few options. Well, we have a few options. I can give you a few ideas, refer you to a I can give you a few ideas, refer you to a

dietician, or would you consider a group like dietician, or would you consider a group like Weight Watchers? Weight Watchers?

GOAL SETTING: “Let me see you back in a GOAL SETTING: “Let me see you back in a month. How much weight will you try lost by month. How much weight will you try lost by then?”then?”

Miller, W.R., & Rollnick, S. (2002). Motivational Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing People for ChangeInterviewing: Preparing People for Change (New (New York, Guilford Press).York, Guilford Press).

Rollnick, S., Mason, P., & Butler, C. (1999). Health Rollnick, S., Mason, P., & Butler, C. (1999). Health Behavior Change: A Guide for PractitionersBehavior Change: A Guide for Practitioners (London, (London, Churchhill Livingstone).Churchhill Livingstone).

Rollnick, S., Miller, W.R., & Dunn, C. (2008). Rollnick, S., Miller, W.R., & Dunn, C. (2008). Motivational Interviewing in Health CareMotivational Interviewing in Health Care (New York: (New York: Guilford Press).Guilford Press).

www.motivationalinterview.org and www.motivationalinterview.org and www.casaa.unm.eduwww.casaa.unm.edu

Useful References & Useful References & ResourcesResources

SummarySummaryMI in 5 StepsMI in 5 Steps

1.1. Establish rapport & Elicit Change Establish rapport & Elicit Change Talk: OARSTalk: OARS

Open questionsOpen questions AffirmationsAffirmations ReflectionsReflections SummarizeSummarize

2.2. Develop Discrepancy to Facilitate Develop Discrepancy to Facilitate change talk using Rulerschange talk using Rulers

3.3. Offer adviceOffer advice4.4. End the interview with a planEnd the interview with a plan

““What to do I do?”What to do I do?”Counseling for Counseling for

Weight LossWeight Loss

Frank J. Domino, M.D.Frank J. Domino, M.D.

ProfessorProfessor

Dept. Family Medicine & Dept. Family Medicine & Community HealthCommunity Health

Un. Of Massachusetts Medical Un. Of Massachusetts Medical SchoolSchool

Barriers to nutritional Barriers to nutritional counselingcounseling

Confusion over current guidelinesConfusion over current guidelines Lack of timeLack of time Lack of insurance compensation Lack of insurance compensation Effectiveness of interventions Effectiveness of interventions Lack of knowledge about nutrition as it Lack of knowledge about nutrition as it

relates to disease relates to disease GOAL: 5 Brief Concepts to Recommend GOAL: 5 Brief Concepts to Recommend

to Patientsto Patients

“ “Successful Losers”Successful Losers”

The National Weight Control RegistryThe National Weight Control Registry

>5000 successful losers>5000 successful losers

Members lost an average of 66 lbs (range=30-300 Members lost an average of 66 lbs (range=30-300 lbs) x 5.5 yearslbs) x 5.5 years

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. 62% watch < 10 hours of TV per week. 62% watch < 10 hours of TV per week. 90% exercise, about 1 hour per day.90% exercise, about 1 hour per day.

http://www.nwcr.wshttp://www.nwcr.ws

What about the average What about the average person?person?

Daily PracticesDaily Practices

Survey 2004 US > 18 Yrs. “Successful Survey 2004 US > 18 Yrs. “Successful Weight Loss Maintainers”Weight Loss Maintainers”

1.1. Eat Fast Food Eat Fast Food < 2/Week< 2/Week

2.2. >> 5 Fruits & Vegetables/day ** AND 5 Fruits & Vegetables/day ** AND

3.3. 150 Minutes physical activity (25 Min/Day)150 Minutes physical activity (25 Min/Day)

What else can your Patients What else can your Patients Do?Do?

3200 Japanese, 30-69 Yrs Survey 2003-63200 Japanese, 30-69 Yrs Survey 2003-6 BMI, Eating “until full” & speed of eatingBMI, Eating “until full” & speed of eating

Odds of Being OverweightOdds of Being OverweightMaleMale FemaleFemale

Eating Till Full Eating Till Full 2.002.00 1.841.84 Eating Quickly Eating Quickly 1.841.84 2.092.09 Full & QuicklyFull & Quickly 3.133.13 3.213.21

Triple the odds !!!Triple the odds !!!BMJ 2008: 337: a2002BMJ 2008: 337: a2002

Eat Slowly and question if still wants moreEat Slowly and question if still wants more

First Some Basics First Some Basics TrainingTraining

CaloriesCalories

Energy IN vs Energy OUTEnergy IN vs Energy OUT 3500 calories= 1 pound3500 calories= 1 pound 500 calories/day x 1 Week = 1 lb500 calories/day x 1 Week = 1 lb +10 calories/day = 1 lb +10 calories/day = 1 lb

weight/yearweight/year

Body WeightBody WeightIdeal Body Weight:Ideal Body Weight:

Women:Women: 100 lbs first 5 feet + 5 lbs/inch. 100 lbs first 5 feet + 5 lbs/inch. +/- 10%+/- 10%

Men:Men: 106 lbs for first 5 feet + 6 lbs/inch 106 lbs for first 5 feet + 6 lbs/inch +/- 10%+/- 10%

Calories Needed to Maintain WeightCalories Needed to Maintain Weight

Active male: Lb Active male: Lb x 15 = total calories per day.x 15 = total calories per day.

Active female: LbActive female: Lb x 12 = total calories per day. x 12 = total calories per day.

Inactive male: Lb Inactive male: Lb x 13 = total calories per day. x 13 = total calories per day.

Inactive female: Lb Inactive female: Lb x 10 = total calories per day.x 10 = total calories per day.

Daily RequirementsDaily Requirements

Female adult (5’4”) ~ 1,500 Female adult (5’4”) ~ 1,500 calories/daycalories/day

Male adult (5’7”) ~ 2,250 calories/dayMale adult (5’7”) ~ 2,250 calories/day

Remember:Remember: Fat = Fat = 99 Kcal/gm Kcal/gm Protein = Protein = 44 Kcal/gm Kcal/gm CHO = CHO = 44 Kcal/gm Kcal/gm Alcohol = Alcohol = 7 7 Kcal/gmKcal/gm

US Recommended Dietary US Recommended Dietary AllowancesAllowances

MalesMales FemalesFemales

WaterWater 4 L/d4 L/d 3 L/d3 L/dCarbohydratesCarbohydrates(50%)(50%) 280 g/d280 g/d 190 190

g/dg/dProtein Protein (20%)(20%) 110 g/d110 g/d 75 g/d75 g/dFat Fat (30%)(30%) 75g/d75g/d 50 g/d50 g/dFiberFiber 35 g/d35 g/d 25 25

g/dg/d

What is a Serving What is a Serving Size?Size?

Meats: 3 oz. (deck of Meats: 3 oz. (deck of cards)cards)

Dairy: 4 oz = ½ cup Dairy: 4 oz = ½ cup Grains: ½ cup or 1 Grains: ½ cup or 1

slice breadslice bread Veg: ½ cup cooked or 1 Veg: ½ cup cooked or 1

cup rawcup raw Fruit: ½ cup cut up or 1 Fruit: ½ cup cut up or 1

mediummedium

The LabelThe Label

Look at Look at serving sizeserving size saturated fatsaturated fat dietary fiberdietary fiber sugarssugars

Glance at Glance at carbohydratecarbohydrate

Read Read ingredientsingredients (for (for hydrogenated oils hydrogenated oils and whole grains)and whole grains)

5 Steps to Healthy Diet5 Steps to Healthy Diet

1.1. Increase FiberIncrease Fiber

2.2. Increase Water 16 Oz before mealsIncrease Water 16 Oz before meals

3.3. Prescribe ExercisePrescribe Exercise

4.4. MINDFULLY Eat Calorie MINDFULLY Eat Calorie “hypodense” foods“hypodense” foods

5.5. Limit Screen Time to < 10 Hr/weekLimit Screen Time to < 10 Hr/week

1. Increase Fiber24 Hour Dietary Recall

“Tell me everything you ate and drank yesterday,

starting with breakfast.”

“Oh no, not yesterday!”

Count Fruit and Vegetable Count Fruit and Vegetable ServingsServings

GoalGoal: 10 servings/day : 10 servings/day 25-30 Grams of Fiber25-30 Grams of Fiber

MinMin: 5 servings/day (15 : 5 servings/day (15 Grams/Day)Grams/Day)

Potatoes, Pasta &White Rice do Potatoes, Pasta &White Rice do NOTNOT count count

OK, NowYou Count

2. Water: 2. Water: Rx: WATER for ChildrenRx: WATER for Children

32 Elementary Schools, 232 Elementary Schools, 2ndnd/3/3rd rd Graders Graders (2950) children x 1 Yr(2950) children x 1 Yr

““Socially Deprived areas” GermanySocially Deprived areas” Germany Water Fountains + 4 lessons Water Fountains + 4 lessons

Overweight: Int=3.8% vs. 6.0%Overweight: Int=3.8% vs. 6.0% 1.1 glasses/day more (220 ml)1.1 glasses/day more (220 ml)

Pedia 2009; 123(4): e661Pedia 2009; 123(4): e661

Water Consumption and DietingWater Consumption and Dietingfor Adultsfor Adults

RCT over 12 weeks of adultsRCT over 12 weeks of adults Compared Low Calorie Diet Compared Low Calorie Diet vs. Low Calorie Diet + 16 Oz vs. Low Calorie Diet + 16 Oz

water prior to each mealwater prior to each meal 44% RRR (~4.5 Lbs) greater 44% RRR (~4.5 Lbs) greater

weight loss in Water group.weight loss in Water group.

Obesity. 2010; 18(2): 300-Obesity. 2010; 18(2): 300-77

Pre Meal water and all you Pre Meal water and all you can eatcan eat

Non Obese adults given 16 ounces water Non Obese adults given 16 ounces water before before ad libitum ad libitum lunchlunch

2 age groups: 21-35 and 60-80 years2 age groups: 21-35 and 60-80 years

Energy Intake andEnergy Intake andhunger measuredhunger measured

Obesity (Silver Spring). 2007 Jan;15(1Obesity (Silver Spring). 2007 Jan;15(1):93-9):93-9

Apples to Oranges…Apples to Oranges…CaloriesCalories

1 Orange 1 Orange 40408 Oz OJ 8 Oz OJ 120 120 8 Oz Cola8 Oz Cola 100100Coffee BlackCoffee Black 2 2Coffee + 2 SugarCoffee + 2 Sugar 3030Coffee + 1 Oz CreamCoffee + 1 Oz Cream 100100Staryucks Café MochaStaryucks Café Mocha 400400

3. Prescribe… EXERCISE3. Prescribe… EXERCISE 6300 adults Observational Study6300 adults Observational Study Dx: Sed Lifestyle HTN, DM, OB, M/SkelDx: Sed Lifestyle HTN, DM, OB, M/Skel ““Inactive” Baseline = Inactive” Baseline = 33% 33%

At 3 Months= 17%; At 3 Months= 17%; At 12 Months = 20%At 12 Months = 20%

BMJ 2008: 337:a2084BMJ 2008: 337:a2084Scandinavian Journal of Medicine and Science in Scandinavian Journal of Medicine and Science in

SportsSports, doi: 10.1111/j.1600-0838.2008.00820.x , doi: 10.1111/j.1600-0838.2008.00820.x

WALK

How Much and What Kind of How Much and What Kind of Exercise????Exercise????

No one knows what is ideal for weight No one knows what is ideal for weight loss.loss.

For CHD: For CHD: 30-50 Min Aerobic exercise 5 days/week.30-50 Min Aerobic exercise 5 days/week.

For Weight loss:For Weight loss: Aerobic + Weight training 5 days per Aerobic + Weight training 5 days per

weekweek

No “after exercise treat”No “after exercise treat”

Why bother?Why bother?

Weight lossWeight lossReduced cardiovascular and all-cause mortalityReduced cardiovascular and all-cause mortalityCognitive benefits. Cognitive benefits.

Anxiolytic effects of exercise: a meta-analysisAnxiolytic effects of exercise: a meta-analysisJ Sports & Exer Psychol. 2008 Aug; J Sports & Exer Psychol. 2008 Aug;

30(f):392-41030(f):392-410Improved quality of life (RCT)Improved quality of life (RCT)

Martin , Exercise dose and quality of life. Arch Martin , Exercise dose and quality of life. Arch Int Med. 2009;169(3):269-78.Int Med. 2009;169(3):269-78.

The cost of NOT exercising: the STRRIDE trialThe cost of NOT exercising: the STRRIDE trialWe are health role modelsWe are health role models

Warburton DE Health benefits of physical Warburton DE Health benefits of physical activity: the evidence. CMAJ. 2006;174(6):801-9.activity: the evidence. CMAJ. 2006;174(6):801-9.

STRRIDE Study: STRRIDE Study: Cost of NOT exercisingCost of NOT exercising

RCT, 4 groupsRCT, 4 groups INTERVENTION: INTERVENTION: Low amount/Mod intensity, Low amount/Mod intensity, Low amount/Vigorous intensity, Low amount/Vigorous intensity, High amount/VigorousHigh amount/Vigorous Low/High: 120 min vs 200 minLow/High: 120 min vs 200 min Intensity: Moderate 40-55% V02 max, High Intensity: Moderate 40-55% V02 max, High

65-80%65-80%

Non-exercisers: +1% body weight, +8.6% Non-exercisers: +1% body weight, +8.6% visceral fat in 6 months!visceral fat in 6 months!

Exercisers: -1-2% body weight, no change/-Exercisers: -1-2% body weight, no change/-7% visc. Fat7% visc. Fat

Slentz CA, STRRIDE; J Appl Physiol. Slentz CA, STRRIDE; J Appl Physiol. 2005;99:1613-8.2005;99:1613-8.

1. Exercise efficiently1. Exercise efficiently

2. Keep your lifestyle 2. Keep your lifestyle activeactive

3. Incorporate resistance 3. Incorporate resistance trainingtraining

Exercising efficiently: Exercising efficiently: Interval training and Interval training and

“threshold”“threshold” HIIT as a health HIIT as a health

promotion strategypromotion strategyGibala, MJ. High-intensity interval Gibala, MJ. High-intensity interval

training: a time efficient strategy training: a time efficient strategy for health promotion? Curr for health promotion? Curr Sports Med Reports. 2007;6:211-Sports Med Reports. 2007;6:211-3.3.

HIIT training HIIT training increases aerobic increases aerobic and anaerobic and anaerobic capacitycapacityTabata I, Nishimura K, et al. Effects Tabata I, Nishimura K, et al. Effects

of moderate-intensity endurance of moderate-intensity endurance and high-intensity intermittant and high-intensity intermittant training on anaerobic capacity training on anaerobic capacity and V02 max. Med Sci Sports and V02 max. Med Sci Sports Exerc. 1996;28(10):1327-30Exerc. 1996;28(10):1327-30 http://www.xiser.com/store/pdf/Sprint_

Interval_Training.pdf

2. Keep lifestyle active 2. Keep lifestyle active

Lifestyle ImportanceLifestyle Importance

DESIGN: 16 week RCT in 40 obese women, DESIGN: 16 week RCT in 40 obese women, both observing similar diet, 16 wk and 1 yr both observing similar diet, 16 wk and 1 yr follow upfollow up

INTERVENTION: structured aerobic activity INTERVENTION: structured aerobic activity or moderate lifestyle activityor moderate lifestyle activity

OUTCOME MEASURES: body weight and OUTCOME MEASURES: body weight and composition changes, cardiovascular risk composition changes, cardiovascular risk profile, physical fitnessprofile, physical fitness

RESULTS: at 1 year, equivalent reductions in RESULTS: at 1 year, equivalent reductions in triglycerides, LDL, HDL, resting DBP; triglycerides, LDL, HDL, resting DBP; lifestyle group had significantly greater lifestyle group had significantly greater reductions in total cholesterol, resting reductions in total cholesterol, resting SBP, increased VO2 max, depression SBP, increased VO2 max, depression scales, maintained weight lossscales, maintained weight loss

Anderson RE, Wadden TA, Bartlett SJ, et al. Effects of lifestyle activity vs structured aerobic Anderson RE, Wadden TA, Bartlett SJ, et al. Effects of lifestyle activity vs structured aerobic exercise in obese women. JAMA. 1999;281:335-340exercise in obese women. JAMA. 1999;281:335-340

3. Incorporate resistance 3. Incorporate resistance trainingtraining

How does resistance How does resistance training provide lasting training provide lasting

benefits?benefits?Muscle mass as a “metabolic sink”Muscle mass as a “metabolic sink”

Increased insulin sensitivityIncreased insulin sensitivity Decreased HbA1c (0.5%-1.0%)Decreased HbA1c (0.5%-1.0%)

Maintain muscle mass lost with age (1 lb/yr after Maintain muscle mass lost with age (1 lb/yr after 50)50)

Increased strength (falls in the elderly!)Increased strength (falls in the elderly!)Increased basal metabolism beyond expected with Increased basal metabolism beyond expected with

adding muscle (21 kcal/kg vs 28-218 kcal/kg)adding muscle (21 kcal/kg vs 28-218 kcal/kg)Reduced visceral fat on par with aerobic exerciseReduced visceral fat on par with aerobic exerciseIncreased bone mineral densityIncreased bone mineral densityRecommend: single set of 8-10 reps covering Recommend: single set of 8-10 reps covering

major muscle groups min 2x/weekmajor muscle groups min 2x/weekBraith RW Circulation. 2006;113:2642-50.Braith RW Circulation. 2006;113:2642-50.

How little is “enough”?How little is “enough”?

Simple answer: whatever you can fit into Simple answer: whatever you can fit into your day, anything is better than nothingyour day, anything is better than nothing

Better answer: Review of observational Better answer: Review of observational cohort studies of exercise and reduction cohort studies of exercise and reduction in all-cause mortalityin all-cause mortality 1000 kcal/week associated with 20-30% risk 1000 kcal/week associated with 20-30% risk

reductionreduction

Haennel RG and Lemire F. Physical activity to prevent cardiovascular disease: How much is Haennel RG and Lemire F. Physical activity to prevent cardiovascular disease: How much is enough? Can Fam Physician. 2002;48:65-71.enough? Can Fam Physician. 2002;48:65-71.

Fitness is more important than Fitness is more important than fatnessfatness

METHODS: 58 sedentary obese men and women, 12 wk supervised METHODS: 58 sedentary obese men and women, 12 wk supervised aerobic exercise (500 kcal, 70% max HR, 5 times/wk)aerobic exercise (500 kcal, 70% max HR, 5 times/wk)

OUTCOME MEASURES: body composition, aerobic capacity, BP, OUTCOME MEASURES: body composition, aerobic capacity, BP, psychological response score, measured at weeks 0 and 12psychological response score, measured at weeks 0 and 12

RESULTS: 26/58 had less than predicted weight loss, but all had RESULTS: 26/58 had less than predicted weight loss, but all had significantly increased aerobic capacity and positive mood, significantly increased aerobic capacity and positive mood, decreased SBP/DBP, waist circumference, resting HRdecreased SBP/DBP, waist circumference, resting HR

The concept of exercise “nonresponder”The concept of exercise “nonresponder” No association between weight loss and improvements in health No association between weight loss and improvements in health

markersmarkers

King NA, Hopkins M, et al. Beneficial effects of exercise: shifting the King NA, Hopkins M, et al. Beneficial effects of exercise: shifting the focus from body weight to other markers of health. Br J Sports Med. focus from body weight to other markers of health. Br J Sports Med. 2009;43:924-7.2009;43:924-7.

I was short, fat and bald when I started running, but after running I was short, fat and bald when I started running, but after running nearly every day for more than 30 years and covering about nearly every day for more than 30 years and covering about 70,000 miles...I am still short, fat, and bald. But I suspect I'm in 70,000 miles...I am still short, fat, and bald. But I suspect I'm in much better shape than I'd be if I didn't run. – Steve Blairmuch better shape than I'd be if I didn't run. – Steve Blair

Workout to recommendWorkout to recommend Warm-up Warm-up HIIT HIIT

20 seconds on/10 20 seconds on/10 seconds offseconds off

8 sets8 sets

Resistance trainingResistance training Turkish getupTurkish getup Kettlebell swingKettlebell swing Squat jumpsSquat jumps

4.4. MindfullyMindfully eating Calorie eating Calorie HypodenseHypodense foods foods

Increase in Increase in awarenessawareness of Eating of Eating Most important part of long Most important part of long

term weight loss and term weight loss and maintenancemaintenance

Divide Plate in Half before eating, Divide Plate in Half before eating, and at ½ point, ask and at ½ point, ask “Am I still “Am I still

Hungry?”Hungry?”

Eat at table, not TV or paperEat at table, not TV or paper

Rolls, BJ et al. Am J Clin Nutr 1999;69:863-871

Hypodense Foods: Hypodense Foods: VolumetricsVolumetrics

People eat a constant People eat a constant weightweight of food each of food each day. day.

Volumetrics: Volumetrics: ↓↓calories but maintain volume. calories but maintain volume.

Energy Density categories:Energy Density categories:

Very lowVery low (<0.6): fruit and vegetables (<0.6): fruit and vegetables

LowLow (0.6-1.5): cereal, cottage cheese, ham (0.6-1.5): cereal, cottage cheese, ham

MediumMedium (1.5-4.0): eggs, bagels, bread products (1.5-4.0): eggs, bagels, bread products

HighHigh (>4.0): cookies, salty snacks, nuts, candy (>4.0): cookies, salty snacks, nuts, candy barsbars

Select foods high in water content, low in fat: Select foods high in water content, low in fat:

fruit, vegetables, soupsfruit, vegetables, soups..

5. Limit Screen Time5. Limit Screen Time Pediatric & Adolescent LiteraturePediatric & Adolescent Literature > 10 hrs/week > 10 hrs/week ↑ Risk of Obesity & T2DM↑ Risk of Obesity & T2DM

Journal of Public Health 2008 30(2):153-Journal of Public Health 2008 30(2):153-160 160

Changing Sedentary to Active Screen Changing Sedentary to Active Screen Time Time Weight Loss Weight Loss

PEDIATRICS; 2006. 118(6) e1831-PEDIATRICS; 2006. 118(6) e1831-e1835 e1835

Eat Together, Get to Bed, & Eat Together, Get to Bed, & Turn off that TV…Turn off that TV…

Cross Sectional analysis of 8550 US ChildrenCross Sectional analysis of 8550 US Children 18% Children Obese (BMI >/= 9518% Children Obese (BMI >/= 95thth percentile) percentile)

Association of childhood obesity & 3 routines:Association of childhood obesity & 3 routines: Eating as a family > 5 nights/weekEating as a family > 5 nights/week Obtaining adequate sleep (>/= 10.5 hr/night)Obtaining adequate sleep (>/= 10.5 hr/night) Limit Screen time (TV, Video, DVD) </= 2 Limit Screen time (TV, Video, DVD) </= 2

Hr/dayHr/day

Habits to EncourageHabits to EncourageDinner w/Family 5/wkDinner w/Family 5/wk

Adequate Sleep (10.5 hr)Adequate Sleep (10.5 hr)

Limiting Screen Time (<2 Hr)Limiting Screen Time (<2 Hr)

Obesity Obesity Children exposed all 3Children exposed all 3 14.3%14.3%

Children exposed to noneChildren exposed to none 24.5%24.5%

Pediatrics 2010; 125: 420-28Pediatrics 2010; 125: 420-28

Other things to Other things to consider…consider…

CalciumCalcium: Calcium is needed for fecal fat : Calcium is needed for fecal fat excretion. Sstematic review found excretion. Sstematic review found supplementation of about 1,200 mg of calcium per supplementation of about 1,200 mg of calcium per day leads to an increase in fecal fat excretion. day leads to an increase in fecal fat excretion. Obes Rev 2009; 10(4): 475-86Obes Rev 2009; 10(4): 475-86

SleepSleep: : A small pilot study compared a low calorie A small pilot study compared a low calorie diet w/either 5.5 hours of sleep vs 8.5 hours over diet w/either 5.5 hours of sleep vs 8.5 hours over 14 days. 8.5 hr had greater weight loss of body 14 days. 8.5 hr had greater weight loss of body fat, and less hunger. The authors postulate it was fat, and less hunger. The authors postulate it was due to the neuroendocrine changes decreased due to the neuroendocrine changes decreased sleep induces. sleep induces. Ann Intern Med 2010; 153: 435-441Ann Intern Med 2010; 153: 435-441

Chronic PPIs: Chronic PPIs: Case control study obesity Case control study obesity developed in patients with GERD who were developed in patients with GERD who were treated chronically with PPIs vs other treatments treated chronically with PPIs vs other treatments World J Gastro 2009; 15(38): 4794-4798World J Gastro 2009; 15(38): 4794-4798..

PPI’s: What to do??PPI’s: What to do?? Moderate-Severe: PPI x 8 weeks, then Step Moderate-Severe: PPI x 8 weeks, then Step

DownDown Mild: H2RA for 8 weeks, then prnMild: H2RA for 8 weeks, then prn

Step Down:Step Down: Double dose for 1 month, then Q Day for one Double dose for 1 month, then Q Day for one

month, then PRNmonth, then PRN Carry AntacidCarry Antacid LIFESTYLE: BEST EVIDENCE: Sleep Left Side, LIFESTYLE: BEST EVIDENCE: Sleep Left Side,

Reduce Stress, Use NSAID’s prn, Smoking Reduce Stress, Use NSAID’s prn, Smoking CessationCessation

Simple ApproachSimple Rule:

Drugs: Looking to Drugs: Looking to 2011…..2011…..

Orlistat: (Xenical) Inhibits Pancreatic Lipase -Orlistat: (Xenical) Inhibits Pancreatic Lipase ->>↓ Intestinal Fat Absorption↓ Intestinal Fat Absorption 6.5 lbs x 12 months6.5 lbs x 12 months

Sibutramine (Meridia): Sibutramine (Meridia): maymay reduce appetite reduce appetite (24 Kg x 1 Yr; no better than placebo; x = 9 lbs)(24 Kg x 1 Yr; no better than placebo; x = 9 lbs)

Qnexa: (phentermine 15 + topiramate 92 Qnexa: (phentermine 15 + topiramate 92 mg)mg) 14% over 56 weeks14% over 56 weeks

Contrave: (bupropion 360 + naltrexone Contrave: (bupropion 360 + naltrexone 32mg) 32mg) 5-7% BW over 24 weeks5-7% BW over 24 weeks

Locaserin: Serotonin antagonistLocaserin: Serotonin antagonist

What are your favorite What are your favorite hints?hints?

SUMMARYSUMMARYSteps to Healthy DietSteps to Healthy Diet

1.1. Increase Fiber: 24 Dietary RecallIncrease Fiber: 24 Dietary Recall2.2. Increase Water 16 Oz before Increase Water 16 Oz before

mealsmeals3.3. Prescribe ExercisePrescribe Exercise4.4. MINDFULLY Eat Calorie MINDFULLY Eat Calorie

“hypodense” foods“hypodense” foods5.5. Limit Screen Time to < 10 Limit Screen Time to < 10

Hr/weekHr/week

Summary: The Other Summary: The Other StuffStuff

Get Adequate SleepGet Adequate Sleep Get RID of the PPI’sGet RID of the PPI’s Add CalciumAdd Calcium Lifestyle, not “diet”Lifestyle, not “diet”