The Duke Diet and Fitness Center

Welcomes

DUKE FOOD WORKING GROUP

October 8, 2014

Putting the Pieces Together: An Intensive,

Multidisciplinary Obesity Treatment Model

DUKE DIET and FITNESS CENTER

GUIDING PRINCIPLE: We need to make permanent, sustainable changes in both food intake and physical activity to lose weight, maintain weight loss, and live a healthier lifestyle

DIET and FITNESS CENTER PROGRAMS:

• Residential weight loss program

– New clients

– Return clients

• Optifast

• Outpatient medical, dietary, and behavioral health consults

• Research

DFC Residential Weight Loss Program Overview

• One-, two-, three-, and four week programs

• Clients from all over the US (and around the globe) to Durham- stay in hotels in the area

• Clients spend all day at the DFC– Building opens at 7AM and closes at 9PM

– Three meals daily + snacks (breakfast and lunch Sat and Sun)

– Exercise classes

– Classroom lectures

– Free time for individual exercise, study, etc.

– Massage, acupuncture, physical therapy, etc. are available

DFC Clients

• Average age: early 50s

• Age range: late teens to nineties

• Gender: 60% women, 40% men

• Average BMI: 38 kg/sq m

• Clients are typically well educated, well informed, upper socioeconomic status, highly motivated to make lifestyle changes

DFC Residential Weight Loss Program Overview

• Four components

– Medical

– Nutrition

– Fitness

– Behavioral Health• All new clients are assessed by professionals in each component during

first few days

• Each component offers classroom lectures in its area of expertise

• Clients return to professionals in each component throughout their DFC programs for check in visits, questions, progress reports, etc.

DFC Residential Weight Loss Program Overview

• Attended by all DFC Treatment Staff (all members of all four components plus Patient Advocate)

• Every week each incoming client is presented and discussed

• Clients who may need special attention or additional evaluation are identified

• Current clients who are not losing weight, are missing meals, are not exercising, etc., are also discussed

• Goal is to have every client be successful!

Weekly Patient Care Conference

DFC Medical Component

• MD and FNP

• Intensively address all obesity related comorbidities

• Serve as Primary Care Providers for clients while at the DFC

• Arrange consultations with Duke specialists

• Lectures

– Overview of Obesity

– Diabetes

– Hypertension

– Lab Interpretation

– Preventive Medicine

– Osteoarthritis

– Weight Loss Medications/Weight Loss Surgery

DFC Outpatient Options

• For local residents

• Outpatient consults for weight loss by

– Medical staff

– Nutrition staff

– Behavioral health staff

• Optifast full and partial meal replacement programs

Putting the Pieces Together:

Nutrition

Developing an Effective, Sustainable

Eating Plan for Long Term Success

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The Diet

• 3 meals daily, snacks optional

• Calorie & Portion based

– 1000 – 1500 kcal

• Clients plan their own menu

– Flexible food choices/diet plans to individualize program

– Gain meal planning skills

– Sustainable, realistic

Food Service

Meriwether Godsey

• Based in Lynchburg, VA

• Local ingredient sourcing as much as possible

• Fresh, scratch made

• Limit use of disposables

– Recycled/Recyclable or compostable

• Limit food waste

– Prep based on menu tally

– Compost food scraps

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Nutrition Treatment Plan

• Nutrition Staff: 2 Registered Dietitians (RD/RDN)

• Week one: 1 hr with RD– Weight & dieting history

– Medical concerns r/t nutrition (diabetes, cholesterol); meds & supplements

– Healthy eating barriers

– Typical daily diet

– Calculate RMR, review calorie prescription

• Optional weekly check-ins (15-30 min)– Monitor progress/tweak

menu

– Answer questions

– Plan for return home

• Support at Home– Dietitian on Demand

– DFC Blog & Facebook

– Recipe updates

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Common Nutrition Related Challenges

What?

• Skipping meals

• Lack fruits & veggies

• Frequent restaurant & processed foods

• Mindless eating

• Emotional eating

• Uncontrolled portions

• Yo-yo & all/nothing dieting

Why?

• Lack of time

• Don’t plan ahead

• “Healthy” foods perceived less convenient

• Temptation (food environment)

• Lack hunger awareness

• Conflicting nutrition information

• Low interest or ability to cook

Nutrition Curriculum

• Nutrition Fundamentals

• Calories & Portions

• Restaurant Strategies

• Grocery Shopping

• Cooking

• Mindful Eating

• Mindless Eating

• Meal Planning

• Volumetrics

• Special Topics

– Fish

– Heart healthy eating

– Power foods

– Anti-inflammatory diet

– Vitamins & minerals

– (Coming soon): Nutrition myths/controversies

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Research/Collaboration Ideas

• Resting Metabolic Rate testing

– Working on IRB proposal

– Prediction Equations, Indirect Calorimetry, RMR, and Obesity

• Diet comparisons

– Varying diet composition (macronutrients; processed foods; artificial sweeteners)

– Effects on gut micro flora

– Long term vs. short term

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Putting the Pieces Together:

Behavioral Health

Building a Bridge Between

Knowledge and Action

From Knowledge to Implementation

I know what I should do…

I just don’t do

it..

If only I had

more time…

If only I felt more motivated

If only…

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Behavioral Health Services at DFC

• Initial 50 minute assessment with one of our clinicians

• Weekly 20-min check in sessions to follow up, answer questions, prepare for home

• Lectures and Groups

• Individual sessions

• Case management during the program

• Outpatient consultation, psychotherapy, post bariatric surgery assistance

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Barriers to Healthy Lifestyle Change

• Too many social events with food and drinks

• Emotional eating

• Lack of support (food/exercise police or the enabler)

• All or nothing mentality

• Unrealistic expectations

• Mood disorders

• Disordered eating (binge eating)

Behavioral Health: Tool Box for Success

• Make lifestyle change a priority (time mgmt)

• Self-monitoring and accountability

• Develop healthy mindset

• Address depression/anxiety/grief

• Managing cues in the environment

• Stress management

• Coping skills for negative emotions

• Realistic goal setting

• Mindfulness

Examples of Behavioral Health Lectures

• Overcoming Emotional Eating

• Stress Management

• Action Planning for Success in the Real World

• Controlling Overeating and Binge Eating

• Enlisting Social Support

• Mindful Awareness Training

• Willpower and Skillpower

• Group: Looking Deeper at Emotional Eating

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Identify Specific Goals and Visions

• Build confidence and hope

• Not just weight loss goals, but lifestyle goals

• Focus on desired outcomes, not what “you don’t want”

Identify Challenges to Implementation and Focus on Specific Action to Follow Through

• If I’m tempted to eat when I’m feeling lonely…. Then I will

– Reach out to a friend that can give me support

– I will remind myself of other times I made it through

– I will reach for something healthy

Preparing for Future Challenges and Set Backs

• Learning from setbacks

• Lifestyle Coaching for ongoing support

• Weekly teleconferences to stay connected with DFC

Putting the Pieces Together:

Fitness

Getting Started in the Right

Direction

Fitness Planning at the Duke DFC

Part 1: Who We Are FITNESS PROFESSIONALS

(Clinical) Exercise Physiologist

Exercise/Fitness Specialist

Certified Personal Trainer

Degrees: Exercise Science/Physiology, Phys Ed/Adult Fitness, Wellness, Health & Human Performance

Certifying Organizations

• ACSM (American College of Sports Medicine)

• NSCA (National Strength and Conditioning Association)

• NASM (National Academy of Sports Medicine)

• ACE (American Council on Exercise)

• Physical Mind Institute, Stott Pilates, etc

Recommended for those requiring exercise supervision/monitoring

Part 2 : What We BelieveOUR PHILOSOPHY

The guiding principles

Exercise & consistent PA are essential to weight control, disease prevention and a healthy lifestyle.

Learn to exercise effectively, safely and successfully. Add more movement to daily life. Create a schedule that fits “your lifestyle”.

Greater focus on PA & benefits of aerobic, strength, and flexibility exercise.

Find who “you” are as an exerciser, explore new ideas,

practice what you can/will do at home.

Part 3 : What We DoFITNESS PROFESSIONAL’S ROLE

• Pre-exercise clearance (including motivation)

– Stress test

– Orthopedic/PT consults

• Fitness Assessment

• Develop relationship with patient

• Guide/Coach patients through planning process for exercise at home

• Goal Setting for home

Typical DFC Fitness Assessment

• Review Medical History (CAD, HTN, DM)

• Orthopedic Limitations/Concerns

• Current PA level (last 3 months) & Past Exercise History

• PA Barriers (internal & external)

• Initial Action Plan for home

• Physical Activity Goals (not weight loss goals!)

• Exercise Prescription: Frequency, Intensity, Time, Type

– At what level/environment will patient succeed (@DFC/@home)?

– Should patient work independently? With Physical Therapy?

Common Orthopedic Concerns and Recommendations

OA

Meniscus

Tendonitis

KNEE LOW BACK HIP

OA

Sciatica

Disc Injury

Bursitis

Rotator Cuff

Quad strength

Core strength/ stability

Flexibility of quads, hamstrings, hips, IT

band

Core strength/ stability

Flexibility of low back, hips, hamstrings

Abductor/Adductor strength

Core strength/stability

Internal/External rotationWeight loss typically leads to some level of

improvement of many orthopedic issues.

OA

Bursitis

Stage of Change Action

Precontemplation Not ready to exercise

Encourage patient to consider exercising; tell patient about health benefits of exercise.

Contemplation Interested in/thinking

about exercise

Independent Supervision Necessary

Write Rx; refer to non-clinical professional

Refer to clinical exercise professional

Preparation Exercising less than

recommended amount

Write Rx; refer to non-clinical professional

Refer to clinical exercise professional

Action & Maintenance Exercising

recommended amount

Encourage continued exercise

Refer to clinical exercise professional

www.ExerciseIsMedicine.org

Physical Activity & Motivation

30 min moderate-intensity cardio; 5 days/wk-OR-

20 min vigorous-intensity cardio; 3 days/wk

ACSM/AHA

Is this optimal for weight loss and/or maintenance?

Weight management guidelines:

60 minutes moderate intensity activity most days

INSTITUTE OF MEDICINE

Physical Activity & Health Guidelines

Frequency Intensity Time Type

Aerobic 4-6 days/wk 50-85% HRR60-85% HRmax

11-14 RPE

Accumulated30-60 mins/day

200-300 mins/wk

Large muscles, rhythmic, continuous

Strength 2-3 days/wkNon-consecutive

Volitional fatigue. Final 2-3 reps should be challenging

1-3 sets8-15 reps20-45 minutes

8-10 exercises; include all major muscle groups

Flexibility 2-3 days/wkminimum

Point of mild discomfort, but not pain

15-30 seconds each stretch; 2-4x/stretch

Static stretching

Neuromotor“Functional”

>2-3 days/wk Challengeappropriate to the individual

>60 mins/wk Balance, coordination,gait, agility

Activities of Daily Living (ADLs)

Use pedometer to establish baseline # of steps; gradually increase toward average of 10,000 steps/day.

EXERCISE GUIDELINES FOR

WEIGHT MANAGEMENT

Class Offerings – Activity & Lecture

• Aqua Aerobics/Aqua Force

• Cardio Interval / Circuit

• Step / Kickboxing

• Chair Aerobics

• Pilates

• Strength, Balance & Stretch

• Gyrokinesis

• Boot Camp

• Restorative Strength (Yoga, Foam Rollers, Pilates)

• Fitness Fundamentals

• Exercise Metabolism

• Getting FIT with Technology

• Components of Fitness (Strength & Flexibility)

• Making Peace with Exercise

• Whats Wrong with My Back? Knee? Shoulder?

Recommended Activities

Aerobic Walking (treadmills/outdoor), biking, elliptical, NuStep, group fitness classes (land & aquatic), swimming

Strength Machine circuit, free weights, resistance bands/tubes, bodyweight, medicine balls, stability balls, water resistance, kettlebells, TRX, BOSU

Flexibility Stretching, yoga, Pilates, Tai Chi, foam rollers, gyrokinesis

Neuromotor“Functional”

Balance discs, BOSU, balance mats/beams, tandem stance/walk, strength exercises combined with balance, Tai Chi, yoga, TRX

ADLs Stairs, short walk breaks at work, park car farther away, housework, yardwork

Sports & Recreation

Tennis, golf, hiking, dancing, kayaking, bowling, Wii

EXERCISE GUIDELINES FOR

WEIGHT MANAGEMENT

Intervention

• Physical activity goal setting (not weight loss goals!)

• Tracking– Garmin Vivofit, FitBit, journal, pedometer, smartphone apps

• Positive support

• BodPod testing

• Educating clients for accurate metabolic expectations

Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it.

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Q & A