Energy Balance <ul><li>“ State in which energy intake, in the form of food and /or alcohol, matches the energy expended, p...
Energy Balance
Estimating Kcal Content in Food  <ul><li>Bomb calorimeter </li></ul><ul><li>Burns food inside a chamber surrounded by wate...
Fat Storage <ul><li>FAT </li></ul><ul><li>Most fat is stored directly into adipose tissue </li></ul><ul><li>Body has unlim...
Protein and Fat Storage <ul><li>Protein is primarily used for tissue synthesis </li></ul><ul><li>Adults generally consume ...
Macronutrients and Fat Storage <ul><li>Body prefers to use CHO as energy source </li></ul><ul><li>Only excess intake of CH...
Energy In Vs. Energy Out NEAT   Basal Metabolism Dietary Intake   Physical Activity Thermic Effect of food
Basal Metabolism  <ul><li>The minimum energy expended to keep a resting, awake body alive </li></ul><ul><li>~60-70% of the...
Influences On Basal Metabolism <ul><li>Body surface area (weight, height) </li></ul><ul><li>Gender </li></ul><ul><li>Body ...
Measurement of Body’s Energy Needs <ul><li>Direct calorimetry </li></ul><ul><ul><li>Measures heat output from the body usi...
Physical Activity <ul><li>Increases energy expenditure beyond BMR </li></ul><ul><li>Varies widely among individuals </li><...
Thermic Effect of Food (TEF) <ul><li>Energy used to digest, absorb, and metabolize food nutrients </li></ul><ul><li>“Sales...
Harris-Benedict Equation <ul><li>Estimates resting energy needs </li></ul><ul><li>Considers height, weight, age, and gende...
Sample Calculations <ul><li>Man :  21 yr., 5’10” (171 cm), 155# (70 kg) </li></ul><ul><li>66.5 + 13.8x( 70kg ) + 5x( 171cm...
Why Do You Eat? <ul><li>Hunger </li></ul><ul><ul><li>Physiological (internal) drive to eat </li></ul></ul><ul><ul><li>Cont...
Satiety Regulator <ul><li>The hypothalamus </li></ul><ul><ul><li>When feeding cells are stimulated, they signal you to eat...
Influences of Satiety
Influences of Satiety
Influenced By Body Composition <ul><li>Leptin  </li></ul><ul><li>A hormone produced by the adipose tissue </li></ul><ul><l...
Hormonal Influence <ul><li>Endorphins </li></ul><ul><ul><li>Natural body tranquilizer that can prompt you to eat </li></ul...
Hormonal Influence <ul><li>Nutrient receptors </li></ul><ul><li>In small intestine </li></ul><ul><li>Elicit feeling of sat...
Nutrients Influence <ul><li>Presence of energy yielding nutrient registers satiety in the brain </li></ul><ul><li>Apolipop...
What is a Healthy Body Weight? <ul><li>Based on how you feel, weight history, fat distribution, family history of obesity-...
Body Mass Index (BMI) <ul><li>The preferred weight-for-height standard  </li></ul><ul><li>Calculation: </li></ul>Body wt (...
Estimation of Healthy Weight For men: 106 pounds for the first 5 feet add 6 pounds per each inch over five feet A man who ...
Obesity <ul><li>Excessive amount of body fat </li></ul><ul><ul><li>Women with > 30-35% body fat </li></ul></ul><ul><ul><li...
Estimation of Body Fat <ul><li>Underwater weighing  </li></ul><ul><li>Most accurate </li></ul><ul><ul><li>Fat is less dens...
Estimation of Body Fat <ul><li>Bioelectrical impedance </li></ul><ul><ul><li>Low-energy current to the body that measures ...
Body Fat Distribution <ul><li>Upper-body (android) obesity--”Apple shape” </li></ul><ul><li>Associated with more heart dis...
Body Fat Distribution
Body Fat Distribution <ul><li>Lower-body (gynecoid) obesity--”Pear shape” </li></ul><ul><li>Encouraged by estrogen and pro...
Overweight and Obesity <ul><li>Underweight = BMI < 18.5 </li></ul><ul><li>Healthy weight = BMI 18.5-24.9 </li></ul><ul><li...
An Epidemic of Obesity
OBESITY <ul><li>61% of adults in the United States were overweight or obese (BMI > 25) in 1999. </li></ul><ul><li>13% of c...
Juvenile-Onset Obesity <ul><li>Develops in infancy or childhood </li></ul><ul><li>Increase in the  number  of adipose cell...
Adult-Onset Obesity <ul><li>Develops in adulthood </li></ul><ul><li>Fewer (number of) adipose cells </li></ul><ul><li>Thes...
Causes of Obesity <ul><li>Nature debate </li></ul><ul><li>Identical twins raised apart have similar weights </li></ul><ul>...
Causes of Obesity <ul><li>Nurture debate </li></ul><ul><li>Environmental factors influence weight </li></ul><ul><li>Learne...
Nature and Nurture <ul><li>Obesity is nurture allowing nature to express itself </li></ul><ul><li>Location of fat is influ...
Nature Vs. Nurture <ul><li>Those at risk for obesity will face a lifelong struggle with weight </li></ul><ul><li>Gene does...
Why Diets Don’t Work <ul><li>Obesity is a chronic disease </li></ul><ul><ul><li>Treatment requires long-term lifestyle cha...
Why Diets Don’t Work <ul><li>Body defends itself against weight loss </li></ul><ul><li>Thyroid hormone concentrations (BMR...
Why Diets Don’t Work <ul><li>Weight cycling (yo-yo dieting) </li></ul><ul><li>Typically weight loss is not maintained </li...
Why Diets Don’t Work <ul><li>Weight gain in adulthood </li></ul><ul><li>Weight gain is common from ages 25-44 </li></ul><u...
Lifestyle Vs. Weight Loss <ul><li>Prevention of obesity is easier than curing </li></ul><ul><li>Balance energy in(take) wi...
What It Takes To Lose a Pound <ul><li>Body fat contains 3500 kcal per pound </li></ul><ul><li>Fat storage (body fat plus s...
Do the Math To lose one pound, you must create a deficit of 2700-3500 kcal So to lose a pound in 1 week (7 days), try cutt...
Sound Weight Loss Program <ul><li>Meets nutritional needs, except for kcal </li></ul><ul><li>Slow & steady weight loss  </...
Cutting Back  <ul><li>Control calorie intake by being aware of kcal and fat content of foods </li></ul><ul><li>“Fat Free” ...
Regular Physical Activity <ul><li>Fat use is enhanced with regular physical activity </li></ul><ul><li>Increases energy ex...
Behavior Modification <ul><li>Modify problem (eating) behaviors </li></ul><ul><li>Chain-breaking </li></ul><ul><li>Stimulu...
Cognitive Restructuring <ul><li>Changing your frame of mind regarding eating </li></ul><ul><li>Replace eating due to stres...
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Energy Balance and Obesity

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Energy Balance and Obesity

  1. 3. Energy Balance <ul><li>“ State in which energy intake, in the form of food and /or alcohol, matches the energy expended, primarily through basal metabolism and physical activity” </li></ul><ul><li>Positive energy balance </li></ul><ul><ul><li>Energy intake > energy expended </li></ul></ul><ul><ul><li>Results in weight gain </li></ul></ul><ul><li>Negative energy balance </li></ul><ul><ul><li>Energy intake < energy expended </li></ul></ul><ul><ul><li>Results in weight loss </li></ul></ul>
  2. 4. Energy Balance
  3. 5. Estimating Kcal Content in Food <ul><li>Bomb calorimeter </li></ul><ul><li>Burns food inside a chamber surrounded by water </li></ul><ul><li>Heat is given off as food is burned </li></ul><ul><li>The increase in water temperature indicates the amount of energy in the food </li></ul>
  4. 6. Fat Storage <ul><li>FAT </li></ul><ul><li>Most fat is stored directly into adipose tissue </li></ul><ul><li>Body has unlimited ability to store fat (as fat) </li></ul><ul><li>CARBOHYDRATES </li></ul><ul><li>Limited CHO can be stored as glycogen </li></ul><ul><li>Most CHO is used as a energy source </li></ul><ul><li>Excessive CHO will be synthesized into fat (for storage) </li></ul>
  5. 7. Protein and Fat Storage <ul><li>Protein is primarily used for tissue synthesis </li></ul><ul><li>Adults generally consume more protein than needed for tissue synthesis </li></ul><ul><li>Excess protein is used as a energy source </li></ul><ul><li>Some protein will be synthesized into fat (for storage) </li></ul>
  6. 8. Macronutrients and Fat Storage <ul><li>Body prefers to use CHO as energy source </li></ul><ul><li>Only excess intake of CHO and protein will be turned into fat </li></ul><ul><li>Fat will remain as fat for storage </li></ul><ul><li>Physical activity encourages the burning of dietary fat </li></ul><ul><li>Beta-oxidation </li></ul><ul><li>Most endurance athletes burn fatty acids for energy </li></ul><ul><li>glycogen is used also </li></ul>
  7. 9. Energy In Vs. Energy Out NEAT Basal Metabolism Dietary Intake Physical Activity Thermic Effect of food
  8. 10. Basal Metabolism <ul><li>The minimum energy expended to keep a resting, awake body alive </li></ul><ul><li>~60-70% of the total energy needs </li></ul><ul><li>Includes energy needed for maintaining a heartbeat, respiration, body temperature </li></ul><ul><li>Amount of energy needed varies between individuals </li></ul>
  9. 11. Influences On Basal Metabolism <ul><li>Body surface area (weight, height) </li></ul><ul><li>Gender </li></ul><ul><li>Body temperature </li></ul><ul><li>Thyroid hormone </li></ul><ul><li>Age (2% decline/decade past 30) </li></ul><ul><li>Kcal intake </li></ul><ul><li>Pregnancy </li></ul><ul><li>Use of caffeine and tobacco </li></ul>
  10. 12. Measurement of Body’s Energy Needs <ul><li>Direct calorimetry </li></ul><ul><ul><li>Measures heat output from the body using an insulated chamber </li></ul></ul><ul><ul><li>Expensive and complex </li></ul></ul><ul><li>Indirect calorimetry </li></ul><ul><ul><li>Measures the amount of oxygen a person uses </li></ul></ul><ul><ul><li>A relationship exists between the body’s production of energy and oxygen </li></ul></ul>
  11. 13. Physical Activity <ul><li>Increases energy expenditure beyond BMR </li></ul><ul><li>Varies widely among individuals </li></ul><ul><li>More activity, more energy burned </li></ul><ul><li>Lack of activity is the major cause of obesity </li></ul>
  12. 14. Thermic Effect of Food (TEF) <ul><li>Energy used to digest, absorb, and metabolize food nutrients </li></ul><ul><li>“Sales tax” of total energy consumed </li></ul><ul><li>~5-10% above the total energy consumed </li></ul><ul><li>TEF is higher for CHO and protein than fat </li></ul><ul><li>Less energy is used to transfer dietary fat into adipose stores </li></ul>
  13. 15. Harris-Benedict Equation <ul><li>Estimates resting energy needs </li></ul><ul><li>Considers height, weight, age, and gender </li></ul><ul><li>For men: </li></ul><ul><li>66.5 + 13.8x(kg) + 5x(cm) - 6.8x(age in yr.) </li></ul><ul><li>For women: </li></ul><ul><li>655.1 + 9.6x(kg) + 1.8x(cm) - 4.7x(age in yr.) </li></ul>
  14. 16. Sample Calculations <ul><li>Man : 21 yr., 5’10” (171 cm), 155# (70 kg) </li></ul><ul><li>66.5 + 13.8x( 70kg ) + 5x( 171cm ) - 6.8x( 21 ) = 1745 kcal/day </li></ul><ul><li>Woman : 21 yr., 5’10” (171 cm), 155# (70kg) </li></ul><ul><li>655.1 + 9.6x( 70kg ) + 1.8x( 171cm ) - 4.7x( 21 )= 1536 kcal/day </li></ul>
  15. 17. Why Do You Eat? <ul><li>Hunger </li></ul><ul><ul><li>Physiological (internal) drive to eat </li></ul></ul><ul><ul><li>Controlled by internal body </li></ul></ul><ul><li>Appetite </li></ul><ul><ul><li>Psychological (external) drive to eat </li></ul></ul><ul><ul><li>Often in the absence of hunger </li></ul></ul><ul><ul><li>e.g., seeing/smelling fresh baked chocolate chip cookies </li></ul></ul>
  16. 18. Satiety Regulator <ul><li>The hypothalamus </li></ul><ul><ul><li>When feeding cells are stimulated, they signal you to eat </li></ul></ul><ul><ul><li>When satiety cells are stimulated, they signal you to stop eating </li></ul></ul><ul><li>Sympathetic nervous system </li></ul><ul><ul><li>When activity increases, it signals you to stop eating </li></ul></ul><ul><ul><li>When activity decreases, it signals you to eat </li></ul></ul>
  17. 19. Influences of Satiety
  18. 20. Influences of Satiety
  19. 21. Influenced By Body Composition <ul><li>Leptin </li></ul><ul><li>A hormone produced by the adipose tissue </li></ul><ul><li>Increases with larger fat mass (and decrease desire to eat) </li></ul><ul><li>Decreases with lower fat mass (and enhance desire to eat) </li></ul><ul><li>Acts to decrease activity of neuropeptide Y </li></ul><ul><li>Neuropeoptide Y </li></ul><ul><li>Increases food intake </li></ul><ul><li>Reduces energy expenditure </li></ul>
  20. 22. Hormonal Influence <ul><li>Endorphins </li></ul><ul><ul><li>Natural body tranquilizer that can prompt you to eat </li></ul></ul><ul><li>CCK </li></ul><ul><ul><li>Along with gastrointestinal distention, decreases hunger (and desire to eat) </li></ul></ul><ul><li>Serotonin </li></ul><ul><ul><li>Neurotransmitter that is released as a result of CHO intake </li></ul></ul><ul><ul><li>High levels appear to decrease desire to eat CHO and induce calmness </li></ul></ul>
  21. 23. Hormonal Influence <ul><li>Nutrient receptors </li></ul><ul><li>In small intestine </li></ul><ul><li>Elicit feeling of satiety </li></ul><ul><li>Communicate with the brain via nerves </li></ul><ul><li>Inform brain of the presence of nutrients in the small intestine </li></ul><ul><li>Feeling of satiety with the infusing of CHO or fats in the small intestine </li></ul>
  22. 24. Nutrients Influence <ul><li>Presence of energy yielding nutrient registers satiety in the brain </li></ul><ul><li>Apolipoprotein A-IV on the chylomicrons signals satiety in the brain </li></ul><ul><li>Absence of these nutrients will signal hunger </li></ul>
  23. 25. What is a Healthy Body Weight? <ul><li>Based on how you feel, weight history, fat distribution, family history of obesity-related disease, current health status, and lifestyle </li></ul><ul><li>Current height/weight standards only provide guides </li></ul>
  24. 26. Body Mass Index (BMI) <ul><li>The preferred weight-for-height standard </li></ul><ul><li>Calculation: </li></ul>Body wt (in kg ) OR Body wt (in lbs) x 703.1 [Ht (in m)] 2 [Ht (in inches)] 2 Health risks increase when BMI is > 25
  25. 27. Estimation of Healthy Weight For men: 106 pounds for the first 5 feet add 6 pounds per each inch over five feet A man who is 5’10” should weigh 166 lbs. For women: 100 pounds for the first 5 feet add 5 pounds per each inch over five feet A women who is 5’10” should weigh 150 lbs.
  26. 28. Obesity <ul><li>Excessive amount of body fat </li></ul><ul><ul><li>Women with > 30-35% body fat </li></ul></ul><ul><ul><li>Men with > 25% body fat </li></ul></ul><ul><li>Increased risk for health problems </li></ul><ul><li>Are usually overweight </li></ul><ul><li>Measurements using calipers </li></ul>
  27. 29. Estimation of Body Fat <ul><li>Underwater weighing </li></ul><ul><li>Most accurate </li></ul><ul><ul><li>Fat is less dense than lean tissue </li></ul></ul><ul><ul><li>Fat floats </li></ul></ul>Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
  28. 30. Estimation of Body Fat <ul><li>Bioelectrical impedance </li></ul><ul><ul><li>Low-energy current to the body that measures the resistance of electrical flow </li></ul></ul><ul><ul><li>Fat is resistant to electrical flow; the more the resistance, the more body fat you have </li></ul></ul><ul><li>X-ray photon absorptiometry </li></ul><ul><ul><li>An X-ray body scan that allows for the determination of body fat </li></ul></ul><ul><li>Infrared light </li></ul><ul><ul><li>Assess the interaction of fat and protein in the arm muscle </li></ul></ul>Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
  29. 31. Body Fat Distribution <ul><li>Upper-body (android) obesity--”Apple shape” </li></ul><ul><li>Associated with more heart disease, HTN, Type II Diabetes </li></ul><ul><li>Abdominal fat is released right into the liver </li></ul><ul><li>Fat affects liver’s ability to clear insulin and lipoprotein </li></ul><ul><li>Encouraged by testosterone and excessive alcohol intake </li></ul><ul><li>Defined as waist to hip ratio of >1.0 in men and >0.8 in women </li></ul>
  30. 32. Body Fat Distribution
  31. 33. Body Fat Distribution <ul><li>Lower-body (gynecoid) obesity--”Pear shape” </li></ul><ul><li>Encouraged by estrogen and progesterone </li></ul><ul><li>Less health risk than upper-body obesity </li></ul><ul><li>After menopause </li></ul><ul><li>upper-body obesity appears </li></ul>
  32. 34. Overweight and Obesity <ul><li>Underweight = BMI < 18.5 </li></ul><ul><li>Healthy weight = BMI 18.5-24.9 </li></ul><ul><li>Overweight = BMI 25-29.9 </li></ul><ul><li>Obese = BMI 30-39.9 </li></ul><ul><li>Severely obese = BMI >40 </li></ul>
  33. 35. An Epidemic of Obesity
  34. 36. OBESITY <ul><li>61% of adults in the United States were overweight or obese (BMI > 25) in 1999. </li></ul><ul><li>13% of children aged 6 to 11 years and 14% of adolescents aged 12 to 19 years were overweight in 1999. This prevalence has nearly tripled for adolescents in the past 2 decades. </li></ul><ul><li>The increases in overweight and obesity cut across all ages, racial and ethnic groups, and both genders. </li></ul><ul><li>300,000 deaths each year in the United States are associated with obesity. </li></ul><ul><li>Overweight and obesity are associated with heart disease, certain types of cancer, type 2 diabetes, stroke, arthritis, breathing problems, and psychological disorders, such as depression. </li></ul><ul><li>The economic cost of obesity in the United States was about $117 billion in 2000. </li></ul>
  35. 37. Juvenile-Onset Obesity <ul><li>Develops in infancy or childhood </li></ul><ul><li>Increase in the number of adipose cells </li></ul><ul><li>Adipose cells have long life span and need to store fat </li></ul><ul><li>Makes it difficult to loose the fat (weight loss) </li></ul><ul><li>Causes </li></ul><ul><li>poor dietary patterns </li></ul><ul><li>lack of physical activity </li></ul><ul><li>43% of adolescents watch 2 hours or more of TV/day </li></ul>
  36. 38. Adult-Onset Obesity <ul><li>Develops in adulthood </li></ul><ul><li>Fewer (number of) adipose cells </li></ul><ul><li>These adipose cells are larger (stores excess amount of fat) </li></ul><ul><li>If weight gain continues, the number of adipose cells can increase </li></ul>
  37. 39. Causes of Obesity <ul><li>Nature debate </li></ul><ul><li>Identical twins raised apart have similar weights </li></ul><ul><li>Genetics account for ~40% of weight differences </li></ul><ul><li>Genes affect metabolic rate, fuel use, brain chemistry </li></ul><ul><li>Thrifty metabolism gene allows for more fat storage to protect against famine </li></ul>
  38. 40. Causes of Obesity <ul><li>Nurture debate </li></ul><ul><li>Environmental factors influence weight </li></ul><ul><li>Learned eating habits </li></ul><ul><li>Activity factor (or lack of) </li></ul><ul><li>Poverty and obesity </li></ul><ul><li>Female obesity is rooted in childhood obesity </li></ul><ul><li>Male obesity appears after age 30 </li></ul>
  39. 41. Nature and Nurture <ul><li>Obesity is nurture allowing nature to express itself </li></ul><ul><li>Location of fat is influenced by genetics </li></ul><ul><li>A child with no obese parents has a 10% chance of becoming obese </li></ul><ul><li>A child with 1 obese parent has a 40% chance </li></ul><ul><li>A child with 2 obese parents has a 80% chance </li></ul>
  40. 42. Nature Vs. Nurture <ul><li>Those at risk for obesity will face a lifelong struggle with weight </li></ul><ul><li>Gene does not control destiny </li></ul><ul><li>Increased physical activity, moderate intake can promote healthy weight </li></ul>
  41. 43. Why Diets Don’t Work <ul><li>Obesity is a chronic disease </li></ul><ul><ul><li>Treatment requires long-term lifestyle changes </li></ul></ul><ul><li>Dieters are misdirected </li></ul><ul><ul><li>More concerned about weight loss than healthy lifestyle </li></ul></ul><ul><ul><li>Unrealistic weight expectations </li></ul></ul>
  42. 44. Why Diets Don’t Work <ul><li>Body defends itself against weight loss </li></ul><ul><li>Thyroid hormone concentrations (BMR) drop during weight loss and make it more difficult to lose weight </li></ul><ul><li>Activity of lipoprotein lipase increases making it more efficient at taking up fat for storage </li></ul>
  43. 45. Why Diets Don’t Work <ul><li>Weight cycling (yo-yo dieting) </li></ul><ul><li>Typically weight loss is not maintained </li></ul><ul><li>Weight lost consists of fat and lean tissue </li></ul><ul><li>Weight gained after weight loss is primarily adipose tissue </li></ul><ul><li>Weight gained is usually more than weight lost </li></ul><ul><li>Associated with upper body fat deposition </li></ul>
  44. 46. Why Diets Don’t Work <ul><li>Weight gain in adulthood </li></ul><ul><li>Weight gain is common from ages 25-44 </li></ul><ul><li>BMR decreases with age </li></ul><ul><li>Inactive lifestyle </li></ul><ul><li>Changes in body composition </li></ul><ul><li>Fluid is usually the first weight lost </li></ul><ul><li>Loss in lean body tissue means lowering the BMR </li></ul><ul><li>Very little fat is lost during weight loss </li></ul>
  45. 47. Lifestyle Vs. Weight Loss <ul><li>Prevention of obesity is easier than curing </li></ul><ul><li>Balance energy in(take) with energy out(put) </li></ul><ul><li>Focus on improving food habits </li></ul><ul><li>Focus on increase physical activities </li></ul>
  46. 48. What It Takes To Lose a Pound <ul><li>Body fat contains 3500 kcal per pound </li></ul><ul><li>Fat storage (body fat plus supporting lean tissues) contains 2700 kcal per pound </li></ul><ul><li>Must have an energy deficit of 2700-3500 kcal to lose a pound per week </li></ul>
  47. 49. Do the Math To lose one pound, you must create a deficit of 2700-3500 kcal So to lose a pound in 1 week (7 days), try cutting back on your kcal intake and increase physical activity so that you create a deficit of 400-500 kcal per day - 500 kcal x 7 days = - 3500 kcal = 1 pound of weight loss day week in 1 week
  48. 50. Sound Weight Loss Program <ul><li>Meets nutritional needs, except for kcal </li></ul><ul><li>Slow & steady weight loss </li></ul><ul><li>Adapted to individuals’ habits and tastes </li></ul><ul><li>Contains enough kcal to minimize hunger and fatigue </li></ul><ul><li>Contains common foods </li></ul><ul><li>Fit into any social situation </li></ul><ul><li>Chang eating problems/habits </li></ul><ul><li>Improves overall health </li></ul><ul><li>See a physician before starting </li></ul>
  49. 51. Cutting Back <ul><li>Control calorie intake by being aware of kcal and fat content of foods </li></ul><ul><li>“Fat Free” does not mean “Calories Free” (or “All You Can Eat”) </li></ul><ul><li>Read food labels </li></ul><ul><li>Estimate kcal using the exchange system </li></ul><ul><li>Keep a food diary </li></ul>
  50. 52. Regular Physical Activity <ul><li>Fat use is enhanced with regular physical activity </li></ul><ul><li>Increases energy expenditure </li></ul><ul><li>Duration and regularity are important </li></ul><ul><li>Make it a part of a daily routine </li></ul>
  51. 53. Behavior Modification <ul><li>Modify problem (eating) behaviors </li></ul><ul><li>Chain-breaking </li></ul><ul><li>Stimulus control </li></ul><ul><li>Cognitive restructuring </li></ul><ul><li>Contingency management </li></ul><ul><li>Self-monitoring </li></ul>
  52. 54. Cognitive Restructuring <ul><li>Changing your frame of mind regarding eating </li></ul><ul><li>Replace eating due to stress with “walking” </li></ul>

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