Obesityepidemic 430


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  • Benefits of regular physical activity in obese persons Regular physical activity is an important component of any weight loss program because it is associated with long-term weight maintenance and has beneficial health effects, such as decreasing coronary heart disease and diabetes, that are independent of weight loss itself. The important physiological and clinical issues regarding the use of physical activity as part of obesity therapy will be reviewed in this section.
  • Physical activity helps preserve fat-free mass during weight loss Approximately 75% of weight that is lost by dieting is composed of fat and 25% is fat-free mass (FFM) [1]. Adding a physical activity program to dietary therapy can affect the composition of weight loss. Two meta-analyses that pooled data from 46 [1] and 28 [2] published trials found that exercise can attenuate the loss of FFM. In subjects with a mean weight loss of 10 kg, regular exercise decreased the percentage of weight lost as FFM by half, from approximately 28% to 13% in men and from 24% to 11% in women ( P <0.05). However, this large difference in percentage of weight lost as FFM represented only a small (approximately 1 kg) difference in the absolute amount of FFM lost between groups. Moreover, conservation of FFM does not necessarily represent conservation of muscle protein; the greater retention of FFM associated with exercise may be related to increased retention of body water and muscle glycogen. It is not known whether performing resistance exercise while dieting leads to greater conservation of FFM than performing endurance exercise because of limited and conflicting data [3,4]. Ballor DL, Poehlman ET. Exercise-training enhances fat-free mass preservation during diet-induced weight loss: a meta-analytical finding. Int J Obes Relat Metab Disord 1994;18:35-40. Garrow JS, Summerbell CD. Meta-analysis: effect of exercise, with or without dieting, on the body composition of overweight subjects. Eur J Clin Nutr 1995;49:1-10. Wadden TA, Vogt RA, Anderson RE, et al. Exercise in the treatment of obesity: effects of four interventions on body composition, resting energy expenditure, appetite and mood. J Consult Clin Psychol 1997;65:269-277. Geliebter A, Maher MM, Gerace L, et al. Effects of strength or aerobic training on body composition, resting metabolic rate, and peak oxygen consumption in obese dieting subjects. Am J Clin Nutr 1997;66:557-563.
  • Energy expenditure of physical activity Physical activity increases metabolic rate. This figure shows the energy expended by selected activities in a 75 kg man. The amount of energy expended depends on the intensity, muscle group involvement, and duration of the activity. The increase in energy consumption associated with an activity occurs primarily during the activity itself. Energy expenditure is also slightly increased after an exercise bout is completed, but the post-exercise increase in metabolic rate is usually short-lived and does not cause an increase in resting energy expenditure the following day. Alpers DH. Undergraduate Teaching Project. Unit XIIIA. Nutrition: energy and protein. American Gastroenterological Association, 1978. Levine J, Baukol P, Ioannis P. The energy expended in chewing gum. N Engl J Med 1999;341:2100.
  • Relationship between physical activity and maintenance of weight loss Although increasing physical activity may not improve short-term weight loss, physical activity may be very important for long-term weight management. However, most long-term (>10 months) prospective randomized controlled trials have not demonstrated a statistically significant beneficial effect of exercise on body weight, when data were analyzed on an intention-to-treat basis [1,2]. The failure to detect a beneficial effect of exercise on body weight may be related to poor compliance with an exercise program. However, large cross-sectional case studies and retrospective analyses of prospective trials found that successful long-term (>1 y) weight loss was associated with participation in regular exercise [3-6]. This figure shows data from one study that found 90% of formerly obese women who achieved and maintained average weight exercised regularly, compared with 34% of obese women who regained weight after successful weight loss ( P <0.001) [3]. Wadden TA, Vogt RA, Anderson RE, et al. Exercise in the treatment of obesity: effects of four interventions on body composition, resting energy expenditure, appetite and mood. J Consult Clin Psychol 1997;65:269-277. Jeffery RW, Wing RR, Thorson C, Burton LR. Use of personal trainers and financial incentives to increase exercise in a behavioral weight loss program. J Consult Clin Psychol 1998;66:777-783. Kayman S, Bruvold W, Stern JS. Maintenance and relapse after weight loss in women: behavioral aspects. Am J Clin Nutr 1990;52:800-807. Marston AR, Criss J. Maintenance of successful weight loss: incidence and prediction. Int J Obes 1984;8:435-439. Jeffery RW, Bjornson-Benson WM, Rosenthal BS, et al. Correlates of weight loss and its maintenance over two years of follow-up among middle-aged men. Prev Med 1984;13:155-168. Hartman WM, Straud M, Sweet DM, Saxton J. Long-term maintenance of weight loss following supplemented fasting. Int J Eat Disord 1993;87-93.
  • Guidelines for increasing physical activity This table summarizes practical guidelines that can be used to help obese patients increase their regular physical activity. An initial assessment is needed to determine: 1) the patient’s current activity profile, 2) his/her readiness to lose weight, 3) the kinds of activities that are physically possible, and 4) barriers that can prevent a successful increase in activity. From this, clinicians should assist patients in developing a physical activity plan, based on information obtained from the initial assessment. Physical activity should be initiated at a low level and gradually increased to a goal of 200 minutes per week in properly selected patients. Activity compliance can be enhanced by increasing lifestyle activities, developing an appropriate home-based exercise program, and considering short bouts rather than long bouts of activity for patients who “ can’t find the time to exercise.”
  • Components of behavioral therapy for obesity Behavioral therapy of obesity usually includes the following components: Self-monitoring is the most important component of behavior therapy for obesity and involves keeping daily records of food intake and physical activity, and checking weight regularly. Self-monitoring records can provide information needed to identify links in the behavior chain that can be targeted for intervention. In addition, record keeping enhances compliance with dietary and physical activity interventions. Problem solving is a systematic method of analyzing problems and identifying possible solutions. Contingency management involves developing methods to help recovery from episodes of overeating or weight regain. Stimulus control is the process of avoiding triggers that prompt eating. Stress management is used to decrease the negative impact of stress on positive behavior patterns. Social support from family members and friends is important for modifying lifestyle behaviors. Cognitive restructuring teaches patients to think in a positive manner and to correct thoughts that undermine weight management efforts. Cognitive techniques also help patients accept realistic, but less-than-desired, weight losses. Inappropriate feelings of failure after achieving modest but clinically-important weight loss can lead to relapse and weight regain. Wadden TA, Foster GD. Behavioral treatment of obesity. Med Clin North Am 2000;84:441-461.
  • Cardinal behaviors of successful long-term weight management Data obtained from the National Weight Control Registry (NWCR) have identified specific behaviors that are associated with successful long-term weight loss [1-3]. Participants enrolled in the registry must have maintained a weight loss of  13.6 kg (  30 lb) for at least 1 year; on average, subjects have maintained a 32 kg (70 lb) weight loss for 6 years . The major behaviors reported by approximately 3000 NWCR participants were: 1) self-monitoring of food intake and body weight; 2) consuming a low-calorie (1300 – 1400 kcal/d) and low-fat diet (20% – 25% of daily energy intake from fat), 3) eating breakfast every day, and 4) performing regular physical activity that expends 2500 to 3000 kcal per week (eg, walking 4 miles per day). Klem ML, Wing RR, McGuire MT, et al. A descriptive study of individuals successful at long-term maintenance of substantial weight loss. Am J Clin Nutr 1997;66:239-246. McGuire MT, Wing RR, Klem ML, et al. Long-term maintenance of weight loss: do people who lose weight through various weight loss methods use different behaviors to maintain their weight? Int J Obes Relat Metab Disord 1998;22:572-577. Wyatt HR, Grunwald GK, Mosca CL et al. Long-term weight loss and breakfast in the National Weight Control Registry. Obes Res 2002;10:78-82.
  • Five steps to facilitate behavior change Five steps that clinical practitioners can take to facilitate behavior changes in their patients are: 1. Identify the specific behavior change that is desired. 2. Review when, where, and how the new behaviors will be performed. 3. Instruct the patient to keep a record of the behavior change. 4. Review the patient’s progress at each treatment visit. 5. Congratulate the patient on successes that have been achieved, but do not criticize failures. Criticism may cause embarrassment and a loss of self-esteem, which may make it uncomfortable for the patient to continue treatment. Wadden TA, Foster GD. Behavioral treatment of obesity. Med Clin North Am 2000;84:441-461.
  • Responding to nonadherence Compliance with behavior and lifestyle changes needed to lose weight and maintain weight loss can be extremely difficult because of genetic background; environmental pressures; and ingrained, life-long behaviors. Practitioners should have realistic expectations and be aware of the considerable barriers that prevent successful weight management in modern society. It is important to control frustration and maintain support when a behavior is not implemented or a goal is not achieved. A nonjudgmental, problem-solving approach will preserve the clinician-patient relationship and allow continued opportunities for productive therapy. Providers can help patients identify barriers, explore how these can be removed, and devise new strategies to achieve the same objectives. This encourages patients to approach weight management more as a set of skills to be learned than as an exercise of willpower. Small, achievable goals give patients successful experiences and provide a foundation for additional lifestyle alterations. Successes should receive positive attention and praise, and even if a goal is not met, the patient's efforts should be commended. Wadden TA, Foster GD. Behavioral treatment of obesity. Med Clin North Am 2000;84:441-461.
  • Recommended nutrient content of a weight-reducing diet Dietary guidelines proposed by the National Institutes of Health [1] recommend a 500 kcal/d deficit for overweight persons (BMI 25.0-29.9 kg/m 2 ) who have obesity-related complications, and for persons with class I obesity (BMI 30-34.9 kg/m 2 ). This energy deficit will result in approximately a 1-lb (0.45 kg) weight loss per week and about a 10% weight reduction at 6 months. A 500-1000 kcal/d deficit is recommended for those with class II (BMI 35.0-39.9 kg/m 2 ) or class III (BMI  40 kg/m 2 ) obesity, which will produce about a 1- to 2-lb weight loss per week and a 10% weight loss at 6 months. The recommended macronutrient composition for a low-calorie weight loss diet is shown in this figure and includes 55% or more of daily calories from carbohydrates, 15% from protein, and 30% or less from fat. In addition, specific recommendations are made regarding the composition of fat ingestion: total energy intake should be comprised of 8%-10% calories from saturated fat, 10% or less calories from polyunsaturated fats, and 15% or less calories from monounsaturated fats. Daily cholesterol intake should not exceed 300 mg/d, and daily fiber intake should be between 20-30 g/d. National Institutes of Health, National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults – The Evidence Report. Obes Res . 1998;6(suppl 2):51S-209S.
  • Suggested energy intake based on initial body weight In practice it is difficult to determine the amount of calories that should be prescribed to achieve a specific energy deficit, because it is difficult to know a patient’s total energy requirements. This table provides suggestions for dietary energy intake based on initial body weight [1]. The estimated energy deficit increases with increasing body weight. The target energy deficit in very heavy patients is higher than those recommended by the NIH guidelines [2], but may be desirable for many patients in these weight categories. Some patien ts may not fully comply with their prescribed diet or the estimate of desired energy intake may be inaccurate. Therefore, dietary energy content should be regularly adjusted based on a trial-and-error approach, to achieve an appropriate rate of weight loss (approximately 1% weight loss per week). Diets containing < 1000 kcal/day may need daily multivitamin supplements, particularly folic acid for women of child-bearing age. Klein S, Wadden T, Sugerman HJ. American Gastroenterological Association Technical Review: Obesity. Gastroenterology 2002 Sep;123(3):882-932. National Institutes of Health, National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report. Obes Res 1998;6(suppl 2):51S-209S.
  • Sources: Bariatric Surgery: A Summary of the Literature, 1990 to 2001
  • Short-term obesity therapy does not result in long-term weight loss Obesity is a chronic disease that requires long-term therapy for successful long-term weight management. Often, patients who are able to lose weight with obesity therapy regain their lost weight after therapy is discontinued. This figure represents data from 76 obese women (mean body mass index 39.4 kg/m 2 ) who were were randomly assigned to one of three treatment groups: 4 months of a very-low-calorie diet (VLCD) of 400 – 500 kcal/d, 6 months of behavior therapy and a 1000 –1 200 kcal/d balanced deficit diet, or 6 months of a combination of a VLCD and behavior therapy. Each treatment program was effective in achieving short-term weight loss. However, most subjects regained a considerable amount of weight by 1 year and had returned to their pretreatment weight at 5 years. Wadden TA, Sternberg JA, Letizia KA, et al. Treatment of obesity by very low calorie diet, behavior therapy, and their combination: a five-year perspective. Int J Obes 1989;13 (suppl 2):39-46.
  • Long-term weight loss is improved with long-term maintenance therapy Maintenance therapy is important for long-term weight management success after initial weight loss is achieved by diet and behavior therapy. In this study, Perri and colleagues [1] randomized obese subjects who lost weight after 5 months of diet and behavior modification therapy to “no maintenance” or a “maintenance program” that involved biweekly contact. At 1 year after initial weight loss was achieved, participants who received maintenance therapy maintained long-term weight loss, whereas those who did not receive maintenance therapy regained half of their lost weight. Perri MG, McAllister DA, Gange JJ, et al. Effects of four maintenance programs on the long-term management of obesity. J Consult Clin Psychol 1988;56:529-534.
  • Obesityepidemic 430

    1. 1. Obesity Epidemic: Nursing's Role Shirley K. Comer RN,MS,JD. Nursing 430 Governors State University
    2. 2. Prevalence <ul><li>Most common chronic disease in the United States. </li></ul><ul><li>Responsible for over 300,000 deaths per year. </li></ul><ul><li>$ 70 billion cost to society each year. </li></ul><ul><li>$ 40 billion spent on treatment annually. </li></ul><ul><li>Has lead to increased morbidity and mortality. </li></ul>
    3. 3. Trends <ul><li>Number of cases has increased 30 percent in the past 10 years. </li></ul><ul><li>Average weight is up 7.9 pounds. </li></ul><ul><li>Obesity rates could double in 30 years. </li></ul>
    4. 4. Obesity <ul><li>Obesity: a person is considered obese when the percentage of body fat, according to age and sex, exceeds 5% of the average percentage for that age and sex classification. -BMI is a common measure expressing the relationship (or ratio) of weight-to-height. It is a mathematical formula in which a person's body weight in kilograms is divided by the square of his or her height in meters (i.e., wt/(ht)2. It is more highly correlated with body fat than any other indicator of height and weight. -Standard weight is based on sitting height and upper arm length. </li></ul>
    5. 5. BMI Graph
    6. 6. Definition <ul><li>BMI Classification </li></ul><ul><ul><li>Normal 18.5 - 24.9 </li></ul></ul><ul><ul><li>Overweight 25.0 - 29.9 </li></ul></ul><ul><ul><li>Obesity </li></ul></ul><ul><ul><ul><li>I 30.0 - 34.9 </li></ul></ul></ul><ul><ul><ul><li>II 35.0 - 39.9 </li></ul></ul></ul><ul><ul><ul><li>III > 40.0 </li></ul></ul></ul><ul><li>Obesity = body weight (relative to body height) > 20% IBW </li></ul><ul><li>Morbid Obesity = > 50% or 100 lb > IBW </li></ul>
    7. 7. Incidence <ul><li>1/3 to 1/2 of American Adults meet criteria for overweight or obesity </li></ul><ul><li>25% of men and 45% of women are trying to lose weight </li></ul><ul><li>Expenditure for weight loss products and services exceeds $33 billion. </li></ul>
    8. 8. Etiology: <ul><li>i) Enzyme deficiency - responsible for alpha-glycerophosphate oxidation. </li></ul><ul><li>ii) Differences in thermogenesis - thin people are better able to dissipate excess calories through heat production. </li></ul><ul><li>iii) Reduced ATPase activity - results in decreased ability to burn calories. </li></ul><ul><li>iv)&quot;Hibernation response&quot; - relic of human evolutionary past initiates overeating . </li></ul>
    9. 9. Etiology <ul><li>v) Genetic </li></ul><ul><ul><li>inheritance of increased # and size of fat cells </li></ul></ul><ul><ul><li>child with one obese parent has 40% chance </li></ul></ul><ul><ul><li>two obese parents has 80% chance </li></ul></ul><ul><li>vi) Socioeconomic factors </li></ul><ul><ul><li>Obesity is more common: </li></ul></ul><ul><ul><ul><li>children & adults from lower socioeconomic grps </li></ul></ul></ul><ul><ul><ul><li>black vs white women </li></ul></ul></ul><ul><ul><ul><li>white vs black men </li></ul></ul></ul><ul><li>vii) Psychological - psychogenic component in 90% of cases, however, it is NOT primary cause. </li></ul>
    10. 10. Obesity Is an Increasingly Common Childhood Condition Age 6 to 11: 4%  13% Age 12 to 19: 5%  14% Growth in Childhood Obesity Over Three Decades If obese at age 6  50% chance of life-long obesity If obese at age 13  75% chance of life-long obesity Blacks Mexican Americans Age 6–19 50% more likely to be obese than whites
    11. 11. A few statistics on childhood obesity: -4% overweight in 1982, and 16% overweight in 1994 -25% of all white children overweight in 2001 -33% African American and Hispanic children overweight 2001 -Hospital costs associated with childhood obesity rising from $35 Million (1979) to $127 Million (1999) Why this is a problem? -New study suggest one in four overweight children is already showing early signs of type 2 diabetes -60% already have one risk factor of heart disease
    12. 12. TV watching and Obesity People who watch T.V. weekly become more obese, the graph shows people who are underweight, and acceptable weight watch T.V. less then people who are overweight and obese. Therefore T.V. Watching has an effect on obesity!!
    13. 14. Obesity Related Diseases -80% of type 2 diabetes related to obesity -70% of Cardiovascular disease related to obesity -42% breast colon cancer diagnosed among obese individuals -30% of gall bladder surgery related to obesity -26% of obese people having high blood pressure Surge in childhood Diabetes -Between 8%-45% of newly diagnosed cases of childhood diabetes are type 2, associated with obesity -4% of childhood diabetes type 2 has risen 20% -Type 2 is most frequent in ages 10-19 -Of children diagnosed with type 2 diabetes, 85% are obese
    14. 15. Obesity Loves Inequity BMI >40: Morbidly Obese Male 60% 29% 4% Female 78% 50% 15% BMI >30: Obese BMI >25: Overweight Obese 27% 23% 21% 16% Diabetic 13% 8% 8% 6% Black Mex. Amer. Male 74% 29% 2% Female 72% 40% 6% White Male 68% 28% 3% Female 58% 31% 5% College Some College High School No High School
    15. 16. Obesity Virtually Guarantees Bad Health Diseases Tied to Obesity School <ul><li>Hypertension </li></ul><ul><li>Type 2 diabetes </li></ul><ul><li>High lipids </li></ul><ul><li>Cardiovascular disease </li></ul><ul><li>Gallbladder disease </li></ul><ul><li>Osteoarthritis </li></ul><ul><li>Stroke </li></ul><ul><li>Respiratory disease </li></ul><ul><li>Some cancers </li></ul>
    16. 17. To Address Obesity, Target the Molecule, Cell, and Population; Not the Individual “ In the human body, as in the world, if you control fuel resources, you influence a lot of other things as well.” Molecular/Chemical Level Population <ul><li> prosperity :  calories </li></ul><ul><ul><li>since 1971 </li></ul></ul><ul><ul><li>+ 335 cal/day for women </li></ul></ul><ul><ul><li>+ 168 cal/day for men </li></ul></ul><ul><li> technology:  exertion </li></ul><ul><li> indoor entertainment:  sedentary behavior </li></ul><ul><li> marketing of poor food: poorer nutrition </li></ul>Fat Cell <ul><li>Not a by-product of individual greed and guilt </li></ul><ul><li>An active organ in its own right </li></ul>– Dr. Gökhan Hotamisligil, Harvard School of Public Health
    17. 18. 1996 2003 Obesity Trends* Among U.S. Adults BRFSS, 1991, 1996, 2003 (*BMI  30, or about 30 lbs overweight for 5’4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25% 1991
    18. 19. Lifestyle Treatments for Weight Loss <ul><li>Successful weight loss and maintenance requires a three-pronged approach: </li></ul><ul><li>1. Changing behavior patterns </li></ul><ul><li>2. Making dietary adjustments </li></ul><ul><li>3. Increasing physical activity </li></ul>
    19. 20. <ul><li>Educate ourselves on available options for obese clients. </li></ul><ul><li>Make sure patients are aware of the risks involved. </li></ul><ul><li>Stress the lifestyle change approach to weight loss. </li></ul>Our Responsibility
    20. 21. The Best Answer <ul><li>Diet and exercise. </li></ul><ul><li>Change bad food habits. </li></ul><ul><li>Start an exercise program. </li></ul><ul><li>Use extreme solutions only for extreme cases. </li></ul><ul><li>Set realistic goals </li></ul><ul><li>Educate pt on effective interventions and prevention </li></ul><ul><li>Identify quack treatments </li></ul>
    21. 22. Realistic body types
    22. 23. Setting Realistic Goals <ul><li>Recognize body type </li></ul><ul><li>can’t change basic type </li></ul><ul><li>can always improve </li></ul><ul><li>Fitness models used to advertise weight loss products and exercise equipment </li></ul><ul><li>most will be unable to achieve similar results </li></ul><ul><li>Appropriate weight loss goal is no more than 2 ponds per week </li></ul><ul><li>Weight loss products seem to offer magic solutions </li></ul>
    23. 24. Recognizing Quacks <ul><li>“All natural” means nothing </li></ul><ul><ul><li>Botanicals? </li></ul></ul><ul><ul><li>Toxins? </li></ul></ul><ul><ul><li>Most products state that they work in conjunction with diet and exercise </li></ul></ul><ul><ul><li>If it offers easy results is a quack product </li></ul></ul><ul><ul><li>Only way to reduce weight is to decrease calories and increase energy output </li></ul></ul>
    24. 25. Changing Behavior Patterns <ul><li>Behavior Modification – an ability to alter lifelong attitudes toward diet and exercise may one of the greatest, but most important, challenges </li></ul><ul><li>Important to set : </li></ul><ul><li>1. Realistic goals </li></ul><ul><li>2. Seek support </li></ul><ul><li>3. Make changes gradually </li></ul><ul><li>4. Become aware of “unhelpful” behaviors </li></ul><ul><li>5. Evaluate “triggers” and relationship with food 6. Practice, practice, practice </li></ul>
    25. 26. Making Dietary Adjustments <ul><li>Diet - derived from the Greek word “diaita”, which means “way of living”. </li></ul><ul><li> 1. Realistic energy level – at least </li></ul><ul><li>10 kcals/lb./day </li></ul><ul><li> 2. Choose foods with low energy density </li></ul><ul><ul><li>3. Cut down on sugar added to foods - sugar </li></ul></ul><ul><ul><li>is the #1 food additive in the U.S. </li></ul></ul><ul><ul><li>accounting for 16% of all calories. </li></ul></ul><ul><ul><li>4. Practice portion control – “super-sizing”. </li></ul></ul><ul><ul><li>5. Consider the calories in beverages </li></ul></ul>
    26. 27. Increasing Physical Activity <ul><li>Physical activity – crucial to success! </li></ul><ul><li>Why? </li></ul><ul><li>1. Burns energy </li></ul><ul><li>2. Speeds metabolism </li></ul><ul><li>3. Helps control appetite </li></ul><ul><li>4. Reduces stress; improves self-esteem </li></ul><ul><li>What & How Much? </li></ul><ul><li>1. Essential activity is enjoyed & suits lifestyle </li></ul><ul><li>2. Aerobic exercise encouraged but </li></ul><ul><li>strengthening & flexibility important too </li></ul><ul><li>Think FIT – F=frequency, I=intensity, T=time </li></ul>
    27. 28. <ul><li>Physical Activity </li></ul><ul><ul><li>Activity and energy expenditure </li></ul></ul><ul><ul><li>Activity and metabolism </li></ul></ul><ul><ul><li>Activity and body composition </li></ul></ul><ul><ul><li>Activity and appetite control </li></ul></ul><ul><ul><li>Activity and psychological benefits </li></ul></ul><ul><ul><li>Choosing activities </li></ul></ul><ul><ul><li>Spot reducing </li></ul></ul>Copyright 2005 Wadsworth Group, a division of Thomson Learning
    28. 29. Benefits of Regular Physical Activity in Obese Persons <ul><li>Decreases loss of fat-free mass associated with weight loss </li></ul><ul><li>Improves maintenance of weight loss </li></ul><ul><li>Improves cardiovascular and metabolic health, independent of weight loss </li></ul>
    29. 30. Physical Activity Helps Preserve Fat-Free Mass During Weight Loss Diet Only Loss of Fat-Free Mass (% Total Weight Loss) Ballor and Poehlman. Int J Obes Relat Metab Disord 1994;18:35. Diet Plus Physical Activity * P <0.05 Men Women
    30. 31. Energy Expenditure of Physical Activity Energy Expenditure (kcal/h) Adapted from: Alpers. Undergraduate Teaching Project. Nutrition: energy and protein. American Gastroenterological Association, 1978. All out competitive sports Running 10 mph Running 6 mph Climbing stairs Sexual intercourse Gardening Walking 4 mph Bicycling Walking 2 mph Chewing gum (11 kcal/h) 400 600 1000 200 800 1200
    31. 32. Relationship Between Physical Activity and Maintenance of Weight Loss Not Maintained Subjects Exercising (%) P <0.001 Kayman et al. Am J Clin Nutr 1990;52:800. Weight Loss Pattern Maintained
    32. 33. Guidelines for Increasing Physical Activity <ul><li>Assessment </li></ul><ul><ul><li>1) Medical and psychological readiness </li></ul></ul><ul><ul><li>2) Physical limitations </li></ul></ul><ul><ul><li>3) Current activities </li></ul></ul><ul><ul><li>4) Barriers to activity </li></ul></ul><ul><li>Develop physical activity plan </li></ul><ul><li>Start activity slowly and gradually increase planned aerobic activity to 200 min/wk </li></ul><ul><li>Enhance compliance </li></ul><ul><ul><li>Programmed vs lifestyle activity </li></ul></ul><ul><ul><li>At-home vs onsite activity </li></ul></ul><ul><ul><li>Multiple short bouts vs single long bout of activity </li></ul></ul>
    33. 34. Components of Behavioral Therapy for Obesity Wadden and Foster. Med Clin North Am 2000:84:441. Self Monitoring Problem Solving Contingency Management Cognitive Restructuring Social Support Stress Management Stimulus Control OBESITY
    34. 35. Successful Long-term Weight Management-Behavior Modification <ul><li>Self-monitoring: </li></ul><ul><ul><li>Diet: record food intake daily, limit certain foods or food quantity </li></ul></ul><ul><ul><li>Weight: check body weight > 1 x/wk </li></ul></ul><ul><li>Low-calorie, low-fat diet: </li></ul><ul><ul><li>Total energy intake: 1300-1400 kcal/d </li></ul></ul><ul><ul><li>Energy intake from fat: 20%-25% </li></ul></ul><ul><li>Eat breakfast daily </li></ul><ul><li>Regular physical activity: 2500-3000 kcal/wk (eg, walk 4 miles/d) </li></ul>Klem et al. Am J Clin Nutr 1997;66:239. McGuire et al. Int J Obes Relat Metab Disord 1998;22:572.
    35. 36. Five Steps to Facilitate Behavior Change Review when, where, and how behaviors will be performed Identify behavior change goal Have patient keep record of behavior change Review progress at next treatment visit Wadden and Foster. Med Clin North Am 2000;84:441. 1 2 5 3 4 Congratulate patient on successes (do not criticize shortcomings)
    36. 37. Responding to Non compliance <ul><li>Do not take patient’s behavior personally </li></ul><ul><li>Assume lack of planning, not motivation, is the problem </li></ul><ul><li>Do not criticize patient ( safeguard their self-esteem) </li></ul><ul><li>Identify obstacles </li></ul><ul><li>Determine how obstacles can be handled in the future </li></ul><ul><li>Acknowledge the difficulty of behavior change and provide encouragement </li></ul><ul><li>Develop a new plan and shorten interval required for success </li></ul>
    37. 38. Portion Sizes <ul><li>In the last few years portions sizes have increased dramatically </li></ul><ul><li>We have become so used to the larger portions that normal portions sizes look too small </li></ul><ul><li>Some researchers have found that patients responded better to reducing portion size vs. counting calories </li></ul>
    38. 39. BAGEL 140 calories 3-inch diameter Calorie Difference: 210 calories 350 calories 6-inch diameter 20 Years Ago Today
    39. 40. COFFEE 20 Years Ago Coffee (with whole milk and sugar) Today Mocha Coffee (with steamed whole milk and mocha syrup) 45 calories 8 ounces 350 calories 16 ounces Calorie Difference: 305 calories
    40. 41. 20 Years Ago Today Calorie Difference: 290 calories 500 calories 4 ounces MUFFIN 210 calories 1.5 ounces
    41. 42. PEPPERONI PIZZA 20 Years Ago Today 500 calories 850 calories Calorie Difference: 350 calories
    42. 43. CHICKEN CAESAR SALAD 20 Years Ago Today 390 calories 1 ½ cups 790 calories 3 ½ cups Calorie Difference: 400 calories
    43. 44. POPCORN 20 Years Ago Today 270 calories 5 cups 630 calories 11 cups Calorie Difference: 360 calories
    44. 45. Recommended Nutrient Content of a Weight-Reducing Diet < 15% Saturated fatty acids Polyunsaturated fatty acids Monounsaturated fatty acids 8%-10% < 10% Carbohydrate > 55% Protein 15% Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults– The Evidence Report. Obes Res. 1998;6 (suppl 2). Fat < 30% Calories: 500-1000 kcal/d reduction Cholesterol: <300 mg/d Fiber: 20-30 g/d
    45. 46. Suggested Energy Intake Based on Initial Body Weight Klein et al. Gastroenterology. 2002 Sep;123(3):882-932. 1000 1500 250-299 1250 1800 300-349 750 1200 200-249 > 1500 2000 > 350 500 1000 150-199 Approximate Initial Energy Deficit (kcal/d) Suggested Energy Intake (kcal/d) Body Weight (lb)
    46. 47. Drugs Are Not the Answer? <ul><li>Weight loss occurring with single drug therapy is typically 10 percent or less. </li></ul><ul><li>Patients are often disappointed with the small change in weight. </li></ul><ul><li>Most desire much greater weight loss than is achieved by drugs alone. </li></ul>
    47. 48. The Alternative <ul><li>Patients have the option of surgical procedure to help them lose weight. </li></ul><ul><ul><li>Must have a BMI of 40 or above. </li></ul></ul><ul><ul><li>Becoming more common. </li></ul></ul><ul><ul><li>Produces results that exceed drug therapy. </li></ul></ul>
    48. 49. Patient Selection Criteria for Bariatric Surgery <ul><li>Surgery indicated in patients with: </li></ul><ul><ul><li>BMI of 40 or over </li></ul></ul><ul><ul><li>BMI of 35 or higher with significant co-morbidity </li></ul></ul><ul><ul><li>Long-standing history of obesity </li></ul></ul><ul><ul><li>Multiple unsuccessful attempts to lose weight using nonsurgical methods </li></ul></ul><ul><ul><li>Ability to comply with dietary and behavioral changes as recommended by the weight management team </li></ul></ul>
    49. 50. Who Is a Surgical Candidate? <ul><li>Meets NIH criteria </li></ul><ul><li>No endocrine cause of obesity </li></ul><ul><li>Acceptable operative risk </li></ul><ul><li>Understands surgery and risks </li></ul><ul><li>Absence of drug or alcohol problem </li></ul><ul><li>No uncontrolled psychological conditions </li></ul><ul><li>Consensus after multidisciplinary team evaluation: </li></ul><ul><ul><li>Primary care clinician, bariatrician, surgeon, psychologist, dietitian, exercise physiologist </li></ul></ul><ul><li>Well-informed, motivated, and dedicated to life-style change and long-term follow-up </li></ul>
    50. 51. % Medical Co-Morbidities Resolved after Bariatric Surgery Wittgrove AC, Clark GW. Laparoscopic Gastric Bypass roux-n-y-500 patients. Obes Surg 2000. And others.
    51. 52. Types of Surgery <ul><li>The most common procedures are: </li></ul><ul><ul><li>Adjustable Gastric Banding (AGB) </li></ul></ul><ul><ul><li>Vertical Banded Gastroplasty (VBG) </li></ul></ul><ul><ul><li>Gastric Bypass or Roux-en-y (RNY) </li></ul></ul><ul><ul><li>Biliopancreatic Diversion (BPD) </li></ul></ul><ul><ul><li>Duodenal Switch (DS) </li></ul></ul>
    52. 53. Adjustable Gastric Binding <ul><li>A band is applied around the top of the stomach. </li></ul><ul><li>The inner lining of the band is a longitudinal balloon. </li></ul><ul><li>About 5% failure rate. </li></ul><ul><li>Simple and safe. </li></ul>
    53. 54. Vertical Banded Gastroplasty <ul><li>Restricts stomach’s capacity by creating a small pouch. </li></ul><ul><li>No malabsorption. </li></ul><ul><li>Vomiting occurs if patient eats too fast, or too large of particles. </li></ul><ul><li>Long term weight loss is not great. </li></ul>
    54. 55. Gastric Bypass or Roux-en-y <ul><li>Major procedure. </li></ul><ul><li>Most popular treatment. </li></ul><ul><li>Stomach is sectioned off, creating a small pouch. </li></ul><ul><li>The pouch usually holds only about one ounce of food. </li></ul>
    55. 56. Gastric Bypass cont. <ul><li>The pouch empties into the small intestine through a dime-size stoma. </li></ul><ul><li>The small hole allows slow emptying to increase satiety. </li></ul><ul><li>Food must be well chewed for passage. </li></ul>
    56. 57. Cont. <ul><li>The part of the small intestine that receives food from the stomach can not metabolize sugars in beverages and sweets. </li></ul><ul><li>Patients often feel ill after eating sugar. </li></ul><ul><li>The inability to tolerate sugars adds to weight loss. </li></ul>
    57. 58. After Gastric Bypass <ul><li>It is common that patients lose 50 percent of their starting weight within the first year. </li></ul><ul><li>Excess skin can be a problem, often patients undergo plastic surgery as a result. </li></ul>
    58. 59. Side Effects of Gastric Bypass <ul><li>About 70 percent develop “dumping syndrome”. </li></ul><ul><li>Decreased absorption of iron, calcium, and vitamin B. </li></ul><ul><li>Mechanisms of action of gastric bypass may include hormonal changes leading to alterations in eating habits and energy expenditure. </li></ul>
    59. 60. Mortality Risk <ul><li>Risk of 0.0% to 2.5%. </li></ul><ul><li>Over time the rate averages 4.5% for those obese patients who did not have the surgery and about 1% for those undergoing gastric bypass. </li></ul><ul><li>Gastric bypass is becoming a successful current treatment method of obesity. </li></ul>
    60. 61. Short-term Obesity Therapy Does Not Result in Long-term Weight Loss Change in Weight (kg) Wadden et al. Int J Obes 1989;13 (Suppl 2):39. 5-year Follow-up 1-year Follow-up End of Treatment Baseline Diet alone Behavior therapy Combined therapy
    61. 62. Long-term Weight Loss is Improved with Long-term Maintenance Therapy Weight Loss (%) Perri et al. J Consult Clin Psychol 1988;56:529. P <0.05 No maintenance tx Maintenance tx Diet and behavior modification therapy 0 1 2 3 4 5 6 7 8 9 10 11 12 Time (mo) 13 14 15 16 17
    62. 63. Fad Diets <ul><li>Ketogenic Diets </li></ul><ul><ul><li>Low CHO intake, body will breakdown fat </li></ul></ul><ul><ul><li>Physiologic problems associated with ketogenic diets: </li></ul></ul><ul><ul><ul><li>Ketosis occurs from incomplete breakdown of fatty acids and are excreted in the urine. Thus, much of the weight loss results from water loss due to body's attempt to excrete accumulating ketone bodies. </li></ul></ul></ul><ul><ul><ul><li>Initial dramatic weight loss - results from consumption of lean body mass. During low CHO diet (ie starvation) body burns protein preferentially. Requires only 480 calories to burn one lb of protein vs 3500 for a lb of fat. </li></ul></ul></ul><ul><ul><li>MD supervision </li></ul></ul>
    63. 64. Fad Diets <ul><li>Examples: Low CHO, High Protein </li></ul><ul><ul><li>Cambridge (330 calories) </li></ul></ul><ul><ul><li>Stillman's Doctor's Quick Weight Loss Diet </li></ul></ul><ul><ul><li>Scarsdale Medical Diet </li></ul></ul><ul><ul><li>Fabulous 14-day Fructose Diet </li></ul></ul><ul><ul><li>Pritikin Diet Plan - 1000 cal diet, 10-15% protein, low fat, high complex CHO (whole grains, fruits, veg.). </li></ul></ul><ul><li>Other </li></ul><ul><ul><li>Grapefruit Diet - based on erroneous theory that it contains enzymes which increase fat metabolism. </li></ul></ul><ul><ul><li>The Beverly Hills Diet - based on false theory that protein and CHO digestive enzymes cannot work together. Thus, should only eat CHO or only protein. </li></ul></ul>
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