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Weight Management


Activity of lipoprotein lipase increases making it more efficient at taking up fat for storage ... Weight lost consists of fat and lean tissue ... – PowerPoint PPT presentation

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Title: Weight Management

Weight Management
The War on Weight
  • 25 of men and 40 of women are trying to lose
  • Approximately 45 million Americans diet each year
  • Nationwide, 55 million Americans are actively
    trying to maintain their weight

The War on Weight
  • Consumers spend about 30 billion per year on
    weight related items. This includes diet sodas,
    diet foods, artificially sweetened products,
    appetite suppressants, diet books, videos and
    cassettes, medically supervised and commercial
    programs, and fitness clubs.
  • Spending on weight loss programs is estimated at
    1 to 2 billion per year.
  • U.S. food manufacturers are estimated to have
    spent 7 billion on advertising of highly
    processed and packaged foods in 1997.

Why Diets Dont Work
  • Obesity is a chronic disease
  • Treatment requires long-term lifestyle changes
  • Dieters are misdirected
  • More concerned about weight loss than healthy
  • Unrealistic weight expectations

Why Diets Dont Work
  • Body defends itself against weight loss
  • Thyroid hormone concentrations (BMR) drop during
    weight loss and make it more difficult to lose
  • Activity of lipoprotein lipase increases making
    it more efficient at taking up fat for storage

Weight Cycling
  • Typically weight loss is not maintained
  • Weight lost consists of fat and lean tissue
  • Weight gained after weight loss is primarily
    adipose tissue
  • Weight gained is usually more than weight lost
  • Associated with upper body fat deposition

Weight Gain in Adulthood
  • Weight gain is common from ages 25-44
  • BMR decreases with age
  • Inactive lifestyle
  • Goal not to gain more than 10-16 pounds more
    than your weight on reaching the age of 21

Changes in Body Composition
  • Fluid is usually the first weight lost
  • Loss in lean body tissue means lowering the BMR
  • Weight loss represents a combined loss of lean
    body tissue and fat

Lifestyle Vs. Weight Loss
  • Prevention of obesity is easier than curing
  • Balance energy in(take) with energy out(put)
  • Focus on improving food habits
  • Focus on increased physical activities

What It Takes To Lose a Pound
  • Body fat contains 3500 kcal/lb
  • Fat storage (body fat plus supporting lean
    tissues) contains 2700 kcal/lb
  • Must have an energy deficit of 2700-3500 kcal to
    lose a pound per week

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 to 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
Sound Weight Loss Program
  • Rate of loss
  • Flexibility
  • Intake
  • Behavior Modification
  • Overall Health

Cutting Back
  • 1200-1500 kcals per day
  • Control calorie intake by being aware of kcal and
    fat content of foods
  • Fat Free does not mean Calories Free (or All
    You Can Eat)
  • Read food labels
  • Estimate kcal using the exchange system
  • Keep a food diary

Regular Physical Activity
  • Fat use is enhanced with regular physical
  • Increases energy expenditure
  • Duration and regularity are important
  • Make it a part of a daily routine

Behavior Modification
  • Modify problem (eating) behaviors
  • Chain-breaking
  • Stimulus control
  • Cognitive restructuring
  • Contingency management
  • Self-monitoring

  • Breaking the link between two behaviors
  • These links can lead to excessive intake
  • Snacking while watching T.V.

Stimulus Control
  • Alternating the environment to minimize the
    stimuli for eating
  • Puts you in charge of temptations

Cognitive Restructuring
  • Changing your frame of mind regarding eating
  • Replace eating due to stress with walking

Contingency Management
  • Forming a plan of action in response to a
  • Rehearse in advance appropriate responses to
    pressure of eating at parties

  • Tracking foods eaten and conditions affecting
  • Helps you understand your eating habits

Weight Maintenance
  • Prevent relapse
  • Occasional lapse is fine, but take charge
  • Continue to practice newly learned behavior
  • Requires motivation, movement, and monitoring
  • Have social support
  • Encouragement from friends/ family/ professionals

Weight Loss Triad
Control Energy Intake
Control Problem Behaviors
Perform Regular Physical Activity
Dieting Can Be Hazardous To Your Health
  • Weight regained consists of a higher percentage
    of body fat than before
  • Less healthy than before dieting
  • Weight loss diet should not be considered unless
    you are committed and motivated

Diet Drugs Amphetamine (Phentermine)
  • Prolongs the activity of epinephrine and
    norepinephrine in the brain
  • Decreases appetite
  • Not recommended for long term use (dependency)

Sibutramine (Meridia)
  • Enhances norepinephrine and serotonin activity
  • Decreases appetite (eat less)
  • Not recommended for people with HTN

Orlistat (Xenical)
  • Inhibits fat digestion
  • Reduces absorption of fat in the small intestine
  • Fat is deposited in the feces, causing side
  • Must control fat intake
  • Malabsorption of fat-soluble vitamins
  • Supplements needed

Very Low-Calorie Diets (VLCD)
  • Recommended for people 30 above their healthy
  • 400-800 kcal per day
  • Low carbohydrates and high protein
  • Causes ketosis
  • Lose 3-4 pounds a week
  • Requires careful physician monitoring
  • Health risks includes cardiac problems and

Bariatric Surgery
  • An increasingly popular option for severely obese
    people who are unlikely to lose weight through
    conventional means
  • Cost 20-35,000
  • Some insurers cover it

Candidates for Bariatric Surgery
  • BMI of 40 or moreabout 100 pounds overweight for
    men and 80 pounds for women
  • BMI between 35 and 39.9 and a serious
    obesity-related health problem such as type 2
    diabetes, heart disease, or severe sleep apnea
  • Willingness to make associated lifestyle changes

Bariatric Surgery
  • Restrictive
  • Malabsorptive
  • Combination restrictive/malabsorptive

Restrictive Surgery Adjustable Gastric Band
Diet After Surgery
  • After restrictive surgeries, patients can only
    eat ½ cup to 1 cup of food at a time
  • Foods often must be soft and chewed thoroughly
  • Patients who eat too fast or the wrong kinds of
    food may have vomiting

Restrictive/Malabsorptive Roux en Y
Diet Books Big Business
  • The original Dr. Atkins Diet Revolution is one of
    the ten best selling books of all time
  • Dr. Atkins New Diet Revolution is still 14 on
    the NYT paperback advice bestseller list (11/04)
    having been on the list for years
  • The South Beach Diet has been on the NYT
    hardcover advice bestseller list for 81 weeks,
    and is currently 4.

Low Carbohydrate Diets (Past)
  • The Scarsdale Medical Diet
  • The Drinking Mans Diet
  • Dr. Atkins Diet Revolution
  • The Marine Corps Diet
  • The Last Chance Diet
  • The Mayo Clinic Diet

Low Carbohydrate Diets (Recent)
  • Enter the Zone
  • Dr. Bob Arnots Revolutionary Weight Control
  • Protein Power
  • Sugar Busters
  • Dr. Atkins New Diet Revolution
  • Feed Your Kids Well (Atkins for Kids)
  • The Fat Flush Plan (Gittleman)
  • The South Beach Diet

Atkins Diet Premise
  • Stabilizes insulin production by limiting carb
    intake. This forces the body from glucosis into
    lipolysis, thus ketones are burned as the primary
    energy source.
  • This results in a metabolic advantage of low
    carbohydrate dieters can lose weight while
    eating more calories

Atkins Diet
  • Induction Phase 2 weeks, 20 g carb/day
  • Eliminate fruit, bread, grains, starchy
    vegetables, dairy products except cheese, cream,
  • 20 g carb 3 cups salad greens, or 2 cups salad
    plus 2/3 cups cooked vegetables such as
    asparagus, summer squash, green beans

Atkins Diet
  • Supplements are recommended for everyone a
    multivitamin, lecithin, L-glutamine, chromium
  • Can purchase supplements from the Atkins
  • Recommends exercise

Atkins Phase 2 OWL
  • Ongoing weight loss phase or Owl.
  • Add carbohydrate at a rate of 5 grams a day until
    weight loss stops
  • This is the CCLL critical carbohydrate level for
  • May be 45, or 33, or 19 grams/day
  • Continue at this level until desired weight is

Atkins Maintenance
  • Determine CCLM critical carbohydrate level for
    maintenance (the level at which weight
  • Most will stabilize at 25 to 90 grams/day
  • If weight gain occurs, return to induction diet

Atkins- Sample Menu Phase 1
  • B scrambled eggs and ham, butter, decaffeinated
    coffee or tea
  • L Bacon cheeseburger, no bun, small tossed
    salad, selzer water
  • D shrimp cocktail with mustard and mayo, clear
    consomme, steak, roast, fish or fowl, tossed
    salad, diet gelatin with whipped cream, sf

Atkins Sample menu OWL
  • B Western omelet, 3 ounces tomato juice, 2 carbo
    grams of bran crispbread, decaf coffee or tea
  • L Chefs salad with ham, cheese, chicken and
    egg zero carbohydrate or oil and vinegar
    dressing, iced herbal tea
  • D Seafood salad, poached salmon, 2/3 cup
    vegetable from permitted list, half cup of
    strawberries in cream

South Beach Diet Premise
  • Addiction to carbs is a psychological need for
    comfort food and is likely a real, physiological
  • Eating bad carbs leads to cravings for more which
    is ultimately responsible for our obesity
  • States that Atkins may limit carbs too severely
  • Stresses glycemic index as the biggest
    determinant of a foods potential impact on body

South Beach Diet Phase 1 (2 weeks)
  • Carbs limited to low-carb vegetables, salads, 1
    milk, fat-free buttermilk, nonfat yogurt.
  • Proteins unlimited lean meats, poultry, fish,
    low fat cheese, tofu
  • Nuts included, but limited
  • Good fats including olive, canola oils
  • Sugar-free hard candies, diet gelatin, sugar subs
  • NO fatty meats, starchy vegetables like corn,
    potatoes, carrots, no fruits, no grains, no

South Beach Sample Day Phase 1
  • B 6 oz tomato juice, 1/4-1/2 cup liquid egg
    substitute, decaf coffee or tea, non-fat milk,
    sugar substitute
  • snack 1-2 turkey roll ups
  • L SB chopped salad with tuna, sf gelatin
  • snack celery, 1 wedge Laughing Cow Light Cheese
  • D baked chix breast, roasted eggplant and
    peppers, salad, lo sugar dressing
  • Dessert Mocha Ricotta Creme

South Beach Diet Phase 2
  • Reintroduces most fruits, whole grains
    (sparingly) including popcorn, legumes such as
    pinto beans, starchy vegetables such as peas,
    carrots and sweet potatoes, flavored nonfat
    yogurt, semisweet or bittersweet chocolate, wine
  • Still forbidden white flour and products made
    from it including breads, cookies, pasta
    potatoes, white rice, corn fruits including
    bananas, canned fruit, pineapple, raisins,
  • Dieters stay in this phase until goal weight

South Beach Sample Day Phase 2
  • B 1 cup blueberries 1 scrambled egg w/ salsa
    oatmeal mixed with 1 cup nonfat milk, sprinkled
    with cinnamon and walnuts coffee or tea
  • Snack 4 oz non-fat sugar-free yogurt
  • L Tuna salad w/ celery, mayo, tomato, onion in
    whole wheat pita
  • Snack 1 part-skim mozzarella cheese stick
  • D Pan roasted steak and onions, South Beach
    salad, steamed broccoli chocolate-dipped

South Beach Diet Phase 3
  • Maintenance- no foods are forbidden
  • Continue to limit high carb, refined or heavily
    processed foods.
  • Return to earlier phase if weight gain occurs

South Beach vs Atkins Phase 1
  • Atkins
  • Proteins All meats, poultry, fish, shellfish,
    eggs, cheese are unlimited
  • Fats vegetable oils, butter, mayonnaise, heavy
    cream, bacon
  • Vegetables 3 cups salad or 2 cups salad and 2/3
    cup low carb vegetables
  • NO artificial sweeteners, margarine, fruits,
    grains, breads, starchy vegetables, dairy,
  • South Beach
  • Proteins Lean beef, pork, skinless poultry, low
    fat cheese, seafood, eggs
  • Fats Canola and olive oil
  • Vegetables salad greens, beans, tomatoes,
    cabbage, summer squash, broccoli, all low carb
    are unlimited
  • Dairy Fat free or 1 milk or yogurt
  • NO fatty meat, high fat cheese fruits, grains,
    breads, starchy vegetables, butter, margarine,

High Carbohydrate Low Fat Diets
  • The Pritikin Weight Loss Breakthrough
  • Eat More, Weigh Less (Dean Ornish)
  • American Heart Association diets
  • NHLBI TLC diet

High Carb Low Fat Diets
  • Rationale diet is high in bulk and fiber, low in
    calorie density producing early satiety and
    weight loss
  • Description 50-75 carbohydrate calories,
    relatively less meat, fish, fats and oils, more
    grains, cereals, breads, fruits, vegetables

Sample Menu High Carb Low Fat
  • B 1 cup blueberries oatmeal mixed with 1 cup
    nonfat milk, sprinkled with cinnamon and walnuts
    coffee or tea
  • Snack 4 oz non-fat sugar-free yogurt
  • L Vegetarian vegetable soup, fresh orange,
    nonfat yogurt
  • D Grilled salmon with yogurt-dill sauce, bulgur
    with raisins, steamed broccoli strawberries over
    angelfood cake
  • Snack air popped popcorn

Research on Macronutrient Mix in Weight Loss Diets
Low Carb vs Low Fat Diet
  • Objective Compare effects of a low-carb,
    ketogenic diet (Atkins) with those of a low-fat,
    low chol, reduced calorie diet
  • Design Randomized, controlled
  • Subjects 120 overweight, hyperlipidemic
  • Intervention Low carb diet (initially carb/day) plus nutritional supplementation,
    exercise recommendation, and group meetings or
    low-fat diet (deficit of 500-1000 kcal/d) plus exercise
    recommendation and group meetings

Yancy, W. S. et. al. Ann Intern Med
Low Carb vs Low Fat Diet
  • Measurements body weight, body composition,
    fasting serum lipid levels and group meetings
  • Results 76 of the low-carb group and 57 of the
    low-fat group completed the study. At 24 weeks
    weight loss was greater in the low-carb group
    (12.9) than in the low-fat group (6.7)
  • Pts in both groups lost more fat mass (-9.4 kg
    low carb, -4.8 kg low-fat) than fat free mass
    (-3.3 kg vs -2.4 kg)
  • Low carb diet subjects had decreases in serum
    triglycerides (-74.2 mg.dL vs. -27.9 mg/dL)

Expected mean body weight over time, by diet group
Yancy, W. S. et. al. Ann Intern Med
Low Carb vs. Low Fat
  • Low carb group had increases in HDL-C (5.5
    mg/dL vs. -1.6 mg/dL P
  • Changes in LDL-C were not significant
  • Low carb group had greater participant retention
    and greater weight loss over 24 weeks
  • Minor adverse effects were more frequent in the
    low-carb diet group
  • Limitations Effects of the low-carb diet and of
    the nutritional supplements could not be
    separated. Participants were healthy and were
    followed for only 24 weeks.

Yancy, W. S. et. al. Ann Intern Med
Low carb vs. conventional 1 year follow up
  • Objective Review the 1-year outcomes of two
    groups randomized to these diets
  • 132 obese adults, BMI 35 or greater 83 had
    diabetes or metabolic syndrome
  • Participants were counseled to either restrict
    carb intake to 500 cals/day with
  • Stern, L. et. al. Ann Intern Med 2004140778-785

Low carb vs. conventional 1 year follow up
  • By 1 year, mean weight change for persons on the
    low carb diet was -5.1 /- 8.7 kg compared with
    -3.1 /- 8.4 kg for persons on a conventional
    diet. Differences were not significant (P 0.20)
  • Triglycerides decreased more on low carb diet,
    HDL levels decreased less, HbA1c improved more
  • Changes in other lipids (LDL, total-C) and
    insulin sensitivity did not differ between groups
  • Limitations 34 drop out rate, suboptimal
    dietary adherence relatively small net weight
    loss in both groups
  • Stern, L. et. al. Ann Intern Med 2004140778-785

Comparison of mean weight loss in kg between
participants on the conventional diet and
participants on the low-carbohydrate diet at 6
months (n 118) and at 1 year (n 126)
Stern, L. et. al. Ann Intern Med 2004140778-785
Low Carb vs. Conventional Diet Outcomes
  • Between 6 months and 1 year, persons in the low
    carb group began to regain weight while persons
    on the conventional diet continued to lose weight
  • By 6 months, there was no significant difference
    in weight loss between the two groups
  • Intake data suggest that differences in weight
    loss, where they exist, are the result of
    differences in calorie intakes, not a metabolic
    advantage of low carb

Summary High Pro Low Carbohydrate Diets
  • Pros
  • High pro low carb diets appear to produce greater
    short term weight loss
  • In studies, there was a lower dropout rate with
    high pro low carb diets
  • High pro low carb diets produced favorable lipid

Summary High Pro Low Carbohydrate Diets
  • Concerns
  • long term safety (effects of high pro diet on
    kidney function, lack of phytochemicals,
    association of ? red meat and ? sfa intake with ?
  • questionable rationale (protein stimulates
    insulin release)
  • difficult to follow long term
  • epidemiological evidence shows vegetarians are
  • at risk nutrients calcium, potassium, vitamin C,
    vitamin D

High Carb Low Fat Diets
  • Pros
  • Fits most major dietary guidelines including U.S.
    Dietary Guidelines, TLC diet, AHA diet high in
    fiber and plant foods associated with health
  • Epidemiological evidence associates high carb low
    fat diets with lower rates of heart disease,
    cancer, obesity
  • Consistent with pattern reported by successful
    dieters in the National Weight Control Registry

Summary High Carb Low Fat Diets
  • Cons
  • Produces more gradual weight loss than high
    protein diets dieters become discouraged
  • Very high carb low fat diets associated with
    unfavorable lipid changes (may need to choose
    whole grains, replace some carb with MFA)
  • At risk nutrients B12, D, E, Zinc

Weight Loss By Any Method Will
  • Reduce blood lipid levels including TC, LDL-C,
    HDL-C, and Tg
  • Improve glycemic control
  • Reduce blood pressure
  • Especially during active weight loss!

Low Carb vs Low Fat
  • Weight loss is caused by a deficit in calories,
    not a metabolic advantage of one over the other
  • Persons with the greatest calorie deficit lost
    the most weight
  • A high protein diet may offer some advantages,
    perhaps in simplicity, limiting options, or
    increased satiety

Low Carb vs Low Fat
  • Many VLCD programs offer a high protein, low
    carb, low fat approach
  • People should be offered options in weight
  • The major issue in diet success is how persons
    plan to keep the weight off

Diet Quality of Popular DietsCSFII Data Healthy
Eating Index
Energy Intake of Adults on Popular DietsCSFII
BMI of Adults on Popular DietsCSFII DATA
BMI Vegetarians/Non VegetariansCSFII DATA
Energy Intake Vegetarians/ Non-Vegetarians
NHLBI Recommendations Diet Therapy for Weight
  • Low calorie diets are recommended for weight loss
    in overweight and obese persons
  • Reducing fat as a part of LCD is a practical way
    to reduce calories.
  • Plan for a deficit of 500-1000 kcal/day for
    weight loss of 1-2 lb/wk

NHLBI Recommendations Physical Activity
  • Physical activity modestly contributes to weight
    loss, may decrease abdominal fat, increases
    cardiorespiratory fitness
  • VERY important for wt maintenance
  • Initially 30-45 minutes moderate activity, 3-5
    days a week
  • Long term 30 minutes of moderate intensity
    activity on most/all days

National Weight Control Registry
  • Self-selected data base of people who have lost
    at least 30 lb and kept it off at least one year
  • Published data on 784 persons, 80 female, 97
    white, 56 with college degrees, mean age 45
  • Had average maximum BMI of 35 most had attempted
    wt loss numerous times

NWCR Weight Loss Methods
NWCR Weight Maintenance Methods
Underweight is Also a Problem
  • 15-25 below healthy weight or BMI of
  • Associated with increased deaths, menstrual
    dysfunction, pregnancy complications, slow
    recovery from illness/surgery
  • Causes are the same as for obesity but in the
    opposite route

Treatment for Underweight
  • Intake of energy-dense foods (energy input)
  • Encourage meals and snacks
  • Reduce activity (energy output)
  • To gain a pound you need a total excess intake of
    2700-3500 kcal
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