Creighton Family Practice

1
Creighton Family Practice

• Birgit Khandalavala

2
Weight Management

• All members of the medical team are equipped to
  help patients with weight loss and
  management-these compromise, physical therapists,
  dieticians, nursing staff and physicians- team
  effort.
• Modest Weight loss is easily done and most
  patients would be able to lose 5-10 of their
  excess weight-
• Keeping it off is the key

3
Why do we gain weight?

• Multifactorial
• Genetic conditions are rare
• Obesogenic environment is the chief cause-FOOD IS
  A TOXIN
• Factors involved are neuro-endocrine, behavioral
  and Physical Activity
• One lifesaver extra a day- one pound per year- 10
  pounds per decade

4
WEIGHT

• WEIGHT GAIN IS DUE TO MORE CALORIES BEING
  CONSUMED THEN EXPENDED
• BASAL METABOLIC RATE THERMIC EFFECT OF FOOD
  PHYSICAL ACTIVITY (INCLUDES NEAT AND PHYSICAL
  EXERCISE)
• Where the weight rests may be the most crucial
  factor-

5
The adipocyte

• Central fat cells are the most metabolically
  active producing hundreds of chemicals
• Inflammation is caused by these chemicals
  damaging the lining of blood vessels
• The more the number of these cells the more the
  resistance to weightloss-
• Overweight folks do not necessarily eat more that
  their thinner colleagues.

6
Emerging hypothesis

• A calorie is still a calorie
• But what the body is genetically programmed to do
  with that calorie is crucial
• May be converting extra sugar into fat and
  depositing this centrally as oppossed to to a
  more peripheral less toxic location
• Fat intake does not put on more fat

7
WEIGHT MANAGEMENT

• DIET
• BEHAVIORAL CHANGE
• PHYSICAL ACTIVITY- NOT ONLY EXERCISE BUT NEAT-
  CAN ACCOUNT FOR 30 MORE CALORIES BURNED- ITS
  GOOD TO FIDGET( LEVINE ET AL)
• WE CAN NOT REALLY CHANGE OUR GENES THRIFTY GENE
  MAY BE TO BLAME somewhat

8
Modalities

• TRIM FOR LIFE
• Healthy THOUGHTS and ROUTINES have to become a
  habit - no diet works - one most try something
  upto 30 times before it can even become close to
  a routine
• INTAKE has to be closely monitored
• Food journals are one of the key components
• MOVEMENT- not only exercise but any activity
• (Moderation- avoidance of calorie dense foods)

9
Putting it into action

• Multipronged approach incorporating
• Nutrition - low carbohydrate, higher protein high
  fiber diet along the lines of South Beach,
  Mediterranean diet, weight watchers, superfoods -
  tries to eliminate simple carbohydrate SUGAR.
  Encouraging good fats, complex carbohydrates and
  high fiber with non animal based protein

10
Behavioral changes

• Avoiding mindless munching
• Smaller portions- probably the most important
  aspect- use a salad plate not a serving platter
• Eating small frequent meals
• Food journals - pieces of paper to elaborate
  online clubs and cell phones
• Recording mood, emotional eating , identifying
  binge eating - can account for 30

11
Pharmacology

• Using weight neutral medications
• Eliminating medications that produce weight gain
  - antidepressants, oral steroids, antipyschotics
• Substitution when possible
• Short term use of certain appetite suppressants
  if behavior and physical activity modifications
  are initiated - Meridia and Xenical are approved
  for the long term
• Treating insulin resistance early

12
Low calorie diets

• Using the optifast system
• Has to be closely supervised
• Outcome may be the same as the less dramatic
  behavioral based programs
• A weight loss of 2-4 pounds a month is excellent-
  especially if kept off

13
How Much to keep off

• 5 is great-
• 10 is better
• Keeping off 5-10 has enormous medical benefits

14
Surgery

• For BMI of over 40 or 35 with
  co-morbidities
• Can help pre-operatively as well as
  post-operativerly - 5 step Creighton Weight
  management program is in place intense medically
  supervised program

15
In the clinic setting

• Patient evaluated for all the comorbidities -
  from head to toe - including liver enzymes,
  diabetes and hypertension, to reduce the risk of
  cardiac disease, certain cancers and potentially
  even alzheimers. Assessment for Sleep apnea.
• Focus not only on weight reduction but on
  decrease in body fat and especially reduction of
  waist measurement - goal is less than 35 inches
  in women and 40 inches in men (Caucasian) May
  turn out to be the single most important
  parameter.Marker of insulin resistance and
  precursor of diabetes etc.

16
Working with your provider

• How ready are you to change
• How motivated are you
• Realistic expectations- 5-10 with diet and
  exercise and a comprehensive program
• Additional 5-10 with medication
• More frequent contact has been the key to long
  term weight maintenance-programs are looking at
  1-2 years.
• Group support, family involvement is
  crucial-TOPS,WW
• Do not focus alone on weight but other parameters
  as well.Be prepared for setbacks,plan ahead
  .Lifelong struggle- so make it a habit.

17
National weight control registry

• Hoping to enroll patients in this ongoing study
  of what works for thousands of patients online
  registry. Has to lose at least 30 pounds and keep
  it off for one year.
• Meanwhile eat breakfast, exercise 45 mins. a day
  at the very least, and eat small frequent meals
  with constant self monitoring- it works
• Good luck to TRIM for life.