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Treatments for Overweight and Obese Clients

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Improved health may require more significant weight loss ... Claims easy, large, fast weight loss. eat all you want, no exercise. uses quackery terms ... – PowerPoint PPT presentation

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Title: Treatments for Overweight and Obese Clients


1
Treatments for Overweight and Obese Clients
  • Dr. David L. Gee
  • FCSN/PE 446
  • Nutrition, Weight Control Exercise

2
(No Transcript)
3
Assessment of Healthy Weight
  • Body Mass Index (25)
  • Risk factors for chronic disease
  • High waist circumference
  • blood pressure (hypertension)
  • blood lipids (dyslipidemia)
  • TC, LDL-C, HDL-C, TG
  • Impaired glucose tolerance
  • family history
  • Presence of obesity related disease

4
The Bottom Line on Weight Control
  • Regardless of the characteristics of a weight
    loss program
  • Negative Energy Balance
  • Results in weight loss
  • E(in) is less than E(out)
  • Positive Energy Balance
  • Results in weight gain
  • E(in) is greater than E(out)
  • Energy Balance
  • Results in weight maintenance
  • E(in) is equal to E(out)

5
Treatment Affecting Energy Intake
  • Listed from low to high risk
  • Healthy diet approach (w/BM)
  • Balanced hypocaloric diet (w/BM)
  • Low Calorie Diet (LCD)
  • Drugs
  • Very Low Calorie Diets
  • Gastric Intestinal Surgery

6
Treatment Affecting Energy Expenditure Losses
  • Increase lifestyle activity
  • Aerobic exercise (w/BM)
  • Strength training (w/BM)
  • Drugs (no prescription drugs currently approved)

7
National Weight Control Registry (University of
Colorado)
  • 3000 people
  • kept 30 lbs off 1year
  • average BMI 35 25
  • Average lost 60 lbs, kept it off for 5 years
  • many were overweight as children (2/3), had one
    or both parents overweight (60)
  • average age 45 yrs
  • http//www.uchsc.edu/nutrition/WyattJortberg/nwcr.
    htm

8
Seven Tips from the National Weight Control
Registry CNN Fat Chance, Nov 2003
  • Expect failures but keep trying
  • Dont view past failures as signs you cant
    succeed
  • Dont deny yourself
  • Plan indulgences
  • Weigh yourself regularly

9
Seven Tips from the National Weight Control
Registry CNN Fat Chance, Nov 2003
  • Exercise regularly
  • Walking most popular
  • Add a little bit of exercise to your daily
    activity
  • Eat a high CHO/low fat diet
  • Eat 5 meals a day

10
Other Tips from the National Weight Control
Registry
  • No pain, no loss
  • Make smaller lifestyle goals
  • Exercise Diet (90)
  • Do what you want, not what you should.

11
Major Dietary Approaches For Weight Loss
  • Healthy Diet/Non-Diet Approach
  • DASH, Food Guide Pyramid
  • Balanced Reduced (Hypocaloric) Diet
  • Weight Watchers, Jenny Craig, Slim Fast
  • Low Carbohydrate Diet
  • Dr. Atkins
  • Restrained Carbohydrate Diet
  • South Beach Diet, Zone Diet

12
Treatments for the Overweight Patient (BMI
25-30) The Non-Diet or Healthy Diet Approach
  • Focus on becoming healthy
  • Success is measured in units of health, not
    units of weight
  • Strategies are lifetime, not temporary
  • Make a commitment because you want to, not
    because you have too.

13
Dietary Modification for the Overweight Patient
  • Focus first on the quality of the diet, second on
    the quantity.
  • Food Guide Pyramid
  • Dietary Guidelines for Americans
  • DASH diet
  • www.nhlbi.nih.gov
  • Focus on fruits, vegetables and whole grains

14
Food Guide Pyramid (the New Food Pyramid has
different pyramids based on energy needs)
15
Portion distortion
16
Healthy Diet Effects
  • Healthy diet may or may not result in weight loss
  • if weight loss occurs, it will be gradual
  • Healthy diet should result in improved health
  • Improved health may require more significant
    weight loss
  • A healthy diet is probably the best diet for
    long-term weight maintenance

17
Final Exam 2005 Required Readings
  • NIH Clinical Guidelines
  • WIN Publications (Weight Information Network)
  • Statistics
  • Weight Cycling
  • Very Low Calorie Diets
  • Surgical Treatments for Obesity
  • Pharmacological Treatments for Obesity
  • Nutrition Club Tuesday, 530PM, 126 Mich
  • 2005-06 officer elections
  • Salmon BBQ

18
Balanced Hypocaloric Diet
  • Low Calorie Diet
  • LCD, not VLCD
  • For those who are
  • significantly overweight
  • BMI 25 w/ health risks
  • can not attain good health without significant
    weight loss

19
Balanced Hypocaloric Diet
  • Negative energy balance
  • Energy In
  • -500 Cal/day energy balance 1 lb fat/week
    weight loss
  • -EB achieved with COMBINED
  • dietary caloric restriction
  • increased exercise
  • plan a net -EB of -500-1000 Cal/day

20
Negative EB is Accumulative
  • If EB - 200 Cal/day
  • decrease food by 100 Cal/day
  • increase activity by 100 Cal/day
  • In one month EB - 6000 Cal
  • at 3500 Cal / lb FAT
  • almost 2 pounds per month
  • over 20 pound per year weight loss

21
Composition of Balanced Hypocaloric Diets
  • Calories
  • reduce intake by about 500 Cal/d
  • minimum of 1000 Cal/d
  • Estimate calories
  • Calculate energy expenditure
  • Food records

22
Composition of Balanced Hypocaloric Diets
  • Low Fat
  • Moderately high in complex CHO
  • 60 of calories
  • Unless pt w/ hypertriglyceridemia
  • Reduce CHO 45-50 of calories
  • Fat 30-35, mainly unsaturated fats
  • Adequate in proteins
  • 0.8 gP/kg BW

23
Forms of Balanced Hypocaloric Diets
  • Meal Plans
  • Dietary exchanges
  • Weight Watchers
  • Commercial Diet Packages
  • Jenny Craig
  • NutriSystems
  • Food Supplement/Food Combos
  • Slim Fast

24
Metabolic and Weight Loss Effects of Long-term
Dietary Intervention in Obese Patients Four-year
Results Flechtner-Mors M, et al. Obes Res.
20008399-402.
  • Randomized controlled trial
  • 75 subjects followed for 4 yrs
  • Control vs Slim-Fast program
  • Wt loss at 4 yrs
  • Control 3.2 SF 8.4
  • Fasting blood glucose at 4yrs
  • Control 13 lower SF12 (ns)
  • Similar findings with fasting insulin
  • Systolic and fasting TG lower in SF group

25
Advantages of Balance Hypocaloric Diets
  • Safe
  • High quality weight loss
  • More similar as a Diet for a lifetime
  • Large volume of food
  • No elimination of any food or food group

26
Disadvantages of Balanced Hypocaloric Diet
  • Another diet
  • going on, going off
  • Slow rate of weight loss
  • think long term
  • No magic, no gimmick

27
Final Exam 2004
  • Exam Format (see 2003 Study Guide linked on
    course web page)
  • No questions on Ergogenic Aids !
  • Short answer/essay
  • Hypothetical case study
  • Data on height, weight, risk factors
  • Do assessment, establish weight goal
  • Common questions a client might ask
  • MC/TF
  • Information that you might be asked from clients
    and health professionals
  • Research studies presented are to reinforce and
    confirm relationships between obesity, weight
    loss and disease risk.

28
Dietary Means to a Healthy Weight Low
Carbohydrate Diets
  • Characteristics
  • Very low in CHO
  • Induction phase
  • Maintenance phase 40-60g/d
  • Restricted intakes of fruit, cereals, pasta,
    bread, potatoes, rice
  • Caloric intake not specified
  • Examples
  • Atkins diet

29
The High Protein/Low Carbohydrate Diets
Rationale The high CHO/insulin link
  • The Claim
  • High CHO diets result in hyperinsulinemia
  • Insulin stimulates fat synthesis
  • therefore high CHO diets result in gaining fat
    weight

30
The High Protein/Low Carbohydrate Diets Flaws in
Rationale
  • The Reality
  • Hyperinsulinemia is a result, not a cause, of
    obesity
  • Although insulin does stimulate fat synthesis
  • fat synthesis only occurs with Energy Balance
  • fat synthesis from CHO is inefficient and with
    EB, body preferentially stores excess dietary
    fat as body fat

31
Carbohydrate intake and biomarkers of glycemic
control among US adults NHANES III AJCN
771426-1433 (2003)
  • 5730 men, 6125 women
  • Cross-sectional NHANES III study
  • Divided into quintiles based on CHO calories
  • No association between CHO intake and
  • HB A1c concentration
  • Fasting plasma glucose
  • Fasting serum insulin
  • this supports current recommendations regarding
    carbohydrate intake in healthy adults.
  • (also note international epidemiological studies)

32
The High Protein/Low Carbohydrate
Diets Rationale Epidemiological Evidence
  • The Claim
  • Since the 1950s FAT has fallen from about 40
    to about 34
  • Since the 1960s the obese has risen from 25
    to about 33
  • Therefore, hi CHO diets have contributed to the
    increase in weight problems

33
The High Protein/Low Carbohydrate Diets Flaws in
Epidemiological Evidence
  • The Reality
  • Studies show that despite an increase in CHO in
    diet, there is increasing obesity.
  • But, while CHO increased FAT decreased
  • TOTAL Calories increased
  • caloric expenditure decreased
  • absolute fat intake stayed the same.

34
The High Protein/Low Carbohydrate Diets Realities
  • Diets low in carbohydrate will deplete glycogen
    stores
  • result in significant early water loss
  • cause premature fatigue during exercise

35
The High Protein/Low Carbohydrate Diets Realities
  • High protein diets will result in further weight
    loss if Ein
  • meat, cheese, egg diets become unappetizing over
    the long run
  • long-term compliance to this restricted diet is
    likely to be poor
  • Diets high in meat … are high in saturated fats
    and may increase risk of heart disease.
  • Short term (during active weight loss) may see
    improvement in blood lipids

36
The High Protein/Low Carbohydrate Diets Realities
  • Low Carbohydrate diets will result in ketosis
  • most cases degree of ketosis are mild
  • most cases there is some appetite suppression
  • in some cases, there will be ketoacidosis and
    electrolyte imbalance - need for physician
    supervision

37
The High Protein/Low Carbohydrate Diets
Conclusions
  • High protein diets will result in short term
    weight loss
  • Long term effectiveness is very questionable
  • Long term effect on health is a concern

38
A Randomized Trial of a Low-Carbohydrate Diet for
Obesity. Foster et al. NEJM 3482082-90 (2003)
  • 66 obese men and women (BMI34)
  • Randomly assigned to diets for 1 year
  • Professional contact minimal to replicate
    approach used by most dieters

39
Weight loss (BW loss)
  • 3 months
  • Low fat 2.7
  • Low cho 6.8 (p0.001)
  • 6 months
  • Low fat 3.2
  • Low cho 7.0 (p0.02)
  • 12 months
  • Low fat 2.5
  • Low cho 4.4 (ns)

40
Changes in risk factors
  • Improved in low CHO diet groups
  • Serum Triglycerides
  • HDL-cholesterol
  • No difference between low CHO and low Fat diet
    groups
  • Blood pressure (ns)
  • LDL-cholesterol
  • NS (but lower in low fat at 3 mo., mean lower at
    12 months)
  • Insulin sensitivity (ns)

41
  • Drop-out rate
  • Low fat 43
  • Low cho 39
  • Reported adverse reactions higher in Low CHO
    group
  • GI problems (diarrhea/constipation)
  • Bad breath
  • Fatigue/weakness
  • headache

42
Low-Carb Diets Summary of Long-term studies
  • What the research shows
  • Short-term outcomes
  • 6 month studies
  • Better weight loss
  • Improved plasma TG and HDL-C
  • drop-out rate significant in both LC and LF
  • Adverse effects greater in LC
  • Long-term outcomes
  • 1 year studies
  • weight loss no better than low fat group
  • still improved plasma TG and HDL-C
  • drop out rate significant in both groups
  • LC eating more CHO than recommended, low SFA,
    high MUFA
  • LF eating more FAT than recommended

43
Dietary Means to a Healthy Weight The
Carbohydrate Restrained Diets
  • Characteristics
  • Lower in CHO than Dietary Guidelines but higher
    than Low Carb diets (40 CHO, 30FAT, 30PRO)
  • Low glycemic index foods encouraged
  • Monounsaturated fats encouraged
  • Examples
  • Zone Diet, South Beach Diet
  • What the research shows
  • Little research available on these diets

44
Very Low Calorie Diets VLCDs
  • Characteristics
  • 400-800 Cal/d
  • Generally semi-synthetic beverages
  • high protein (50-100g/d)
  • Very low fat
  • Low to moderate CHO
  • Expensive

45
Very Low Calorie Diets VLCDs
  • Must be Medically Supervised
  • Generally safe
  • Minor side effects
  • Fatigue
  • Constipation or diarrhea
  • Nausea/dizziness
  • Cold intolerance
  • Possible significant side effects
  • Gall stones
  • Electrolyte imbalances

46
Very Low Calorie Diets VLCDs
  • Patient Criteria
  • BMI 30
  • BMI 27-30 with medical complications
  • Contraindications
  • Pregnancy
  • Children
  • history of
  • dysrhythmia of heart
  • gall stones
  • renal dysfunction

47
Very Low Calorie Diets VLCDs
  • Short term outcome
  • Rapid high quality weight loss
  • 30-35 kg in 25 weeks
  • Reduction in health risks
  • Long term success
  • No more (or less) successful than other
    treatments
  • Maintenance program (diet, behavior, exercise)
    critical for success

48
(No Transcript)
49
Guidelines for Identifying Weight Loss Fraud
  • Claims easy, large, fast weight loss
  • eat all you want, no exercise
  • uses quackery terms
  • gets rid of cellulite
  • relies on undocumented cases

50
Guidelines for Identifying Weight Loss Fraud
  • Claims government approval
  • gives no or incomplete scientific references
  • cures everything
  • promotes use of unproven aids/gadgets
  • equipment
  • supplements

51
Guidelines for Identifying Weight Loss Fraud
  • Makes claims about problems associated with
    combining certain foods in the same meal
  • Describes diet as being opposed by the the
    established medical community
  • Distributed exclusively by mail order, internet,
    800 phone, pyramid sales organization

52
Remaining Fall 2002 Schedule
  • 12/2
  • Hi PRO/low CHO diets
  • VLCD see web notes and WIN web reading
  • Exercise and weight loss
  • BM/assessment assignment due
  • Turn in
  • your BM records
  • SOAP notes for your client
  • 12/4
  • Pharmacological approaches to weight loss
  • 12/6
  • Surgical methods for weight loss
  • 12/13
  • 830-10 Final Exam

53
RCT Atkins Diet E. Westman, Duke
Univ. presented at 2002 AHA annual meeting
  • Funded by R. Atkins Foundation
  • 120 overweight subjects
  • Randomized
  • Atkins diet
  • AHA step 1 diet (US Dietary Guidelines)
  • 6 months

54
RCT Atkins Diet What does this mean?
  • Greater adherence due to novelty?
  • ADA step 1 diet not much different than typical
    diet
  • Dont ignore 100s of studies of CHD dangers of
    high SFA/chol diets
  • Based primarily on stable weight
  • This is a short term study
  • Long term weight loss success
  • Effect of weight maintenance on blood lipids
  • Provocative, but…wait and see!

55
Extra Credit Opportunity
  • Replaces the 25pt Eating Behaviors Project
  • Worth 5 extra credit points
  • Write a 2 page commentary on the USA Today
    article
  • Kids need school's help to get healthy
  • http//www.usatoday.com/news/health/2003-05-19-fit
    kids-usat_x.htm
  • To get all 5 points, your commentary must be
  • Thoughtful (and realistic)
  • Well organized
  • Well written
  • typed

56
Characteristics of a Healthy Diet
  • Low Fat, Low Saturated Fat
  • reduces CHD, Hpt, cancer risks
  • lowers caloric density and may reduce food intake
  • reducing dietary fat alone without reducing
    calories is insufficient

57
Characteristics of a Healthy Diet
  • High in Fiber
  • reduces CHD cancer risks
  • reduces caloric density
  • Low in Sugar
  • reduces caloric density
  • often associated with high fat foods

58
Characteristics of a Healthy Diet
  • Moderation in salt and alcohol
  • reduces hpt, CHD, cancer risks
  • alcoholic beverages high caloric density

59
Findings RCT Atkins Diet
  • AHA step 1 diet
  • Wt loss 20 lbs
  • LDL-C no change
  • TG 22 drop
  • HDL-C unchanged
  • Atkins Diet
  • Wt loss 31 lbs
  • LDL-C no change
  • TG 49 drop
  • HDL-C 11 increase
  • Fewer drop-outs

60
A Low-Carbohydrate as Compared with a Low-fat
Diet in Severe Obesity. Samaha et al. NEJM
3482074-81(2003)
  • 132 severely obese (BMI43)
  • Randomly assigned to low-CHO or low- Fat diets
    for six months
  • Weight loss at 6 months
  • Low-fat 1.9kg
  • Low-CHO 5.8kg

61
  • Triglyceride change
  • Low fat -7mg/dl
  • Low cho -38 mg/dl (p
  • LDL-C
  • Low fat 3mg/dl
  • Low cho 5mg/dl (ns)
  • HDL-C
  • Low fat - 1mg/dl
  • Low cho 0 mg/dl (ns)
  • Hemoglobin A1c
  • Low fat 0
  • Low cho -0.6 (p.06)

62
  • Dietary changes
  • Caloric intake
  • Low fat -271 Cal/day
  • Low cho -460 Cal/day (ns)
  • Fat intake ( of calories)
  • Low fat 33 to 33
  • Low cho 33 to 41 (p
  • Drop-out rate at 6 months
  • Low fat 47
  • Low cho 33 (ns)
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