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OWCH Online Weight management Counseling program for Healthcare providers

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Title: OWCH Online Weight management Counseling program for Healthcare providers


1
OWCHOnline Weight management Counseling program
for Healthcare providers
  • Module 2
  • Lifestyle Practices for Weight Management
    Health Promotion
  • Yale-Griffin Prevention Research Center
  • www.yalegriffinprc.org

2
Module 2
  • Module 1 described the problem of the obesity
    epidemic and the importance of lifestyle
    counseling.
  • This module provides guidance for nutrition and
    physical activity prescriptions for weight
    management and optimum health.

3
  • Eating alone will not keep a man well he must
    also take exercise. For food and exercise, while
    possessing opposite qualities, yet work together
    to produce health. For it is the nature of
    exercise to use up material, but of food and
    drink to make good deficiencies...
  • Hippocrates, 400 B.C.

4
  • Nutrition Recommendations

5
Basics for a Healthful Diet
  • Experts from the American Heart Association,
    the USDA (United States Department of
    Agriculture), and the American Cancer Society all
    agree that a health-promoting diet consists of
    the following
  • Grains- at least ½ should be whole grain
  • Fruits and vegetables in a variety of colors and
    types (the new recommendations for adults are 9
    servings per day, 4 fruits and 5 vegetables)
  • Lean protein- includes 2 servings of fish per
    week, and 4 servings of low and no-fat dairy
    products
  • www.health.gov/dietaryguidelines/

6
(No Transcript)
7
Determining Caloric Needs
  • Everyone has unique caloric needs.
  • Two methods to calculate individual caloric needs
    follow.
  • The first calculation is easier but provides an
    approximation.
  • The second calculation requires more computation
    but is more accurate.
  • Consider referring patients to a
    dietitian/nutritionist.
  • A calorie calculator can be accessed at
  • www.bcm.edu/cnrc/caloriesneed.htm

8
Method 1
  • To maintain current body weight
  • Determine weight in kilograms (1kg2.2lb).
  • Determine activity level (use chart below to
    calculate.
  • Calculate energy needs in calories (kcal) based
    on activity level.
  • To lose Weight subtract 500 kcals per day
    for a 1 lb. wt. loss per wk.

9
Method 2The Harris-Benedict Equation
  • Uses age, height, and weight to estimate basal
    energy expenditure (BEE) (aka BMR) (amount of
    calories needed to maintain the body's normal
    metabolic activity, i.e. respiration, maintenance
    of body temperature etc.)
  • For women, the B.E.E. 655.1 (9.6 x Wt. kg)
    (1.8 x Ht. cm) - (4.7 x Age)
  • For men, the B.E.E. 66.5 (13.8 x kg) (5.0
    x Ht. cm) - (6.8 x Age)

10
Method 2, contdThe BEE value is then
multiplied by an activity factor to estimate
daily calories needed to maintain current
weight.To lose weight, subtract 500 calories
per day for a 1 lb. weight loss per week.
ACTIVITY FACTOR ACTIVITY DESCRIPTION
Very Light 1.3 for both women men Seated and standing activities, driving, cooking, playing a musical instrument
Light 1.5 for women 1.6 for men Golf, sailing, housecleaning, childcare, walking 2.5-3.0 mph
Moderate 1.6 for women 1.7 for men Dancing, skiing, tennis, cycling, walking 3.5-4.0 mph
Heavy 1.9 for women 2.1 for men Basketball, football, soccer, climbing
11
Improving the Typical American Diet
  • Control portion size and total calorie intake
  • Replace bad fats with good fats
  • Reduce trans-fat saturated fat consumption
  • Reduce refined carbohydrates
  • Increase whole grains consumption
  • Increase fiber intake
  • Reduce sodium intake
  • Increase micronutrient consumption
  • Increase fruit and vegetable consumption
  • Katz DL. TIME Magazine / ABC News Summit on
    Obesity Williamsburg, VA June 2004

12
Summary of Nutrition Recommendations
  • 1. To maintain a healthy body weight, balance
    calories consumed with calories burned.
  • 2. Increase awareness of daily caloric
    requirements and calorie content of foods for
    portions typically consumed.
  • 3. Consume a diet rich in a wide variety of
    fruits and vegetables (not fruit juices),
    especially that that are brightly colored
    (spinach, carrots, peaches, and berries, etc.).
  • 4. Prepare foods with little or no saturated or
    trans fat, salt, or sugar.
  • 5. Choose whole-grain, high-fiber foods.

13
Summary of Nutrition Recommendations, contd
  • 6. Minimize beverages and foods with added
    sugars.
  • 7. Choose lean meats or vegetable protein
    alternatives and fat-free (skim) or low-fat (1
    fat) dairy products to avoid excess saturated fat
    cholesterol.
  • 8. Eat 2 servings of fish twice weekly,
    especially those high in omega-3 fatty acids
    (e.g., salmon, trout, herring).  (Children and
    pregnant women should follow FDA guidelines for
    avoiding mercury-contaminated fish such as shark,
    swordfish, king mackerel, tilefish.)
  • 9. Be aware of portion size and foods prepared
    with saturated fats, salt or sugar when eating
    out.

14
Summary of Nutrition Recommendations, contd
  • 10. Limit sodium intake to lt 2,300 mg of sodium
    daily prepare foods with little or no salt
    beware of processed foods.
  • Older adults, African Americans, and
    hypertensive patients should consume no gt1,500
    mg of sodium daily.
  • 11. Limit alcohol intake to no gt1 drink per day
    for women and 2 drinks per day for men (1 drink
    12 oz of beer, 4 oz of wine, 1.5 oz of 80-proof
    spirits, or 1 oz of 100-proof spirits).

15
Convey the Importance of Label Reading
Daily Values are based on a 2,000 calorie
diet. Website to understandand see the
Nutrition Facts label http//www.cfsan.fda.gov/d
ms/foodlab.htmlsee1
16
Energy Balance
17
Energy Balance
  • Energy balance is key to weight control.
  • In order to lose weight, calorie expenditure must
    be greater than calories intake (negative energy
    balance).
  • One pound of body fat represents a reserve of
    approximately 3500 kcal.
  • To lose 1 pound per week, a deficit of 500
    calories per day is required.
  • This can be achieved through increased physical
    activity and/or decreased caloric intake.
  • Spiegelman BM et al. Obesity and regulation of
    energy balance. Cell 2001 104 531-543

18
Energy Balance
  • Physical inactivity and sedentary lifestyles lead
    to caloric imbalance and the development of
    obesity.
  • Adjustments in caloric intake and the frequency,
    duration intensity of exercise are needed to
    promote weight loss.
  • http//mechanismsincardiology.com/

10
19
Intake
Expenditure
A cookie and a Soda 200 calories
Walking for 45 minutes 200 calories
Every day
73,000 calories a year A 22 pound increase a
year
73,000 of calories a year A 22 pound decrease
20
Physical Activity
21
Physical Activity
  • A reduction in calorie intake without physical
    activity will result in a decline in the Resting
    Metabolic Rate thus inhibiting weight loss.
  • Combining physical activity with a balanced diet
    is key to achieving sustainable weight loss and
    associated health benefits.
  • To promote and maintain health, adults require
    moderate-intensity aerobic (endurance) physical
    activity for a minimum of 30 minutes on five days
    each week or vigorous-intensity aerobic physical
    activity for a minimum of 20 min on three days
    each week.
  • Shorter 10 minute bouts of activity may be
    performed to reach the 30 minute goal.
  • Weinsier RL. Do Adaptive changes in metabolic
    rate favor weight regain in weight-reduced
    individuals? An examination of the set-point
    theory. Am J Clin Nutr 2000 72 1088-1094.
  • American College of Sports Medicine. ACSMs
    Guidelines for exercise testing and prescription.
    7th Edition. Lippincott- Williams Wilkes
  • Physical activity recommendations included in the
    Dietary Guidelines for Americans 2005 (US
    Department of Health and Human Services, 2005

22
Physical Activity
  • A variety of activities can be combined to meet
    the recommendation.
  • To prevent unhealthy weight gain some adults must
    exceed minimum requirements to achieve energy
    balance (45-60 minutes of moderate physical
    activity per day).
  • To sustain weight loss in adulthood Participate
    in at least 6090 min of daily moderate-intensity
    physical activity while not exceeding caloric
    intake requirements.
  • Haskell W, et al. Physical Activity and Public
    Health Updated Recommendation for Adults from
    the American College of Sports Medicine and the
    American Heart Association. MEDICINE SCIENCE IN
    SPORTS EXERCISE. 2007 Am College of Sports
    Medicine and Am Heart Assoc

23
Physical Activity
  • A dose-response relationship exists between
    physical activity and health activity above
    recommended minimum increased benefits.
  • Weight training on 2 non-consecutive days is
    recommended to enhance skeletal muscle strength
    and endurance
  • 8-12 exercises using major muscles
  • 8-12 repetitions of each exercise to volitional
    fatigue.
  • Haskell W, et al. Physical Activity and Public
    Health Updated Recommendation for Adults from
    the American College of Sports Medicine and the
    American Heart Association. MEDICINE SCIENCE IN
    SPORTS EXERCISE. 2007 Am College of Sports
    Medicine and Am Heart Assoc

24
Resistance Training and Energy Expenditure
  • Increasing the body muscle mass via resistance
    training (weight
  • lifting) can increase resting energy expenditure
    by 30-50 kcal/lb
  • muscle a day.
  • Example if 20 minutes of resistance training
    3 times a week for a duration of 6 weeks adds
    4lbs. of muscle, 200 extra kcal per day would be
    burned as a result of an increase in the resting
    metabolic rate.

25
Strategies to incorporate physical activity into
daily life
  • Take the stairs.
  • Park further away.
  • Stand up and take walks throughout the day.
  • Schedule exercise time.
  • Join a fitness group or club.

26
Physical Activity Rx
  • To attain the maximum health benefits from
    physical activity, exercise should be prescribed.
  • The exercise prescription consists of the FITT
    acronym
  • 1)      Frequency
  • 2)      Intensity
  • 3)      Time
  • 4)      Type

27
Frequency
  • At least 5 times a week of moderate physical
    activity or 3 times a week of vigorous activity.
  • At least 2 times a week of progressive weight
    training.

28
Intensity
  • Methods to measure intensity include
  • Talk test
  • Target heart rate
  • Borgs rating
  • METS (metabolic equivalent)
  • http//www.cdc.gov/nccdphp/dnpa/physical/measuring
    /talk_test.htm

29
Talk Test
  • This method of determining intensity is very
    basic
  • Light intensity able to sing while being
    active.
  • Moderate intensity - able to talk but not sing.
  • Vigorous activity unable to say more than a
    few words without taking a breath (unable to
    carry on a conversation).

30
Target Heart Rate
  • Determine if the pulse or heart rate is within
    the target zone during physical activity
  • Moderate intensity 50-70 of the maximum heart
    rate
  • Vigorous intensity 70-85 of the maximum heart
    rate
  • Maximum heart rate (MHR) can be assessed in a
    sports
  • medicine laboratory or estimated
  • 220 age MHR for males
  • 226 age MHR for females
  • www.cdc.gov/physicalactivity/everyone/measuring/he
    artrate.html
  • Waburton d, et al. Prescibing exercise as
    preventive therapy. CMAJ 2006l 174L961-74.

31
Examples of Target Heart Rate
  • Moderate intensity exercise (50-70 MHR)
  • Example Target Heart Rate for a 45 year old man
  • HR max (220 age) 220 45 175 beats/min
  • 50 - 70 of MHR 88 -123 beats/min
  • High-intensity exercise (70-85 MHR)
  • Example Target Heart Rate for a 25 year old man
  • HR max (220 age) 220 25 195 beats/min
  • 70 -85 of MHR 137 - 166 beats/min
  • www.cdc.gov/physicalactivity
  • Waburton DER et al. Prescribing exercise as
    preventive therapy. CMAJ 2 2006 174 961-974.

32
Borgs Rating of Perceived Exertion
  • Borgs Rating is based on the physical sensations
    a person experiences during physical activity.
  • The scale ranges from 6 to 20, where 6 means "no
    exertion at all" and 20 means "maximal exertion.
  • Borgs rating of 12-14 would be moderate
    intensity activity.
  • Although this is a subjective measure, a high
    correlation exists between a person's perceived
    exertion rating times 10 and the actual heart
    rate during physical activity. For example, if a
    person's rating of perceived exertion (RPE) is
    12, then 12 x 10 120 the heart rate should be
    approximately 120 beats per minute.
  • http//www.cdc.gov/physicalactivity/everyone/measu
    ring/exertion.html

33
METS - Metabolic Equivalent
  • MET or the standard metabolic equivalent is a
    unit used to estimate the amount of oxygen used
    by the body during physical activity.
  • 1 MET BMR (energy (oxygen) used by the body at
    rest)
  • With increased activity, more oxygen is
    consumed and the MET level increases.
  • 3 to 6 METs moderate-intensity physical
    activity.
  • gt 6 METs vigorous-intensity physical activity.

34
METs examples
3 6 METS gt 6 METS
Brisk walk Jogging, running, speed walking
Bicycling lt 10 mph Bicycling gt 10 mph
Ballroom dancing Swimming laps
General gardening Heavy gardening
Tennis, doubles Tennis, singles
Weight lifting- Nautilus or free weights Circuit training
35
Time
  • Accumulate total minimum of 30 minutes of
    moderate activity or 20 minutes of vigorous
    activity per day for weight maintenance.
  • Schedule one routine time for exercise, or
  • Split total time into 2 or 3 exercise sessions
    throughout day.

36
Time, contd
  • Higher intensity exercise burns more calories in
    shorter time period, but may increase the risk of
    injury.
  • Lower intensity exercise for a longer duration is
    recommended for beginners (e.g., brisk walking).
  • As fitness level increases, increase either time,
    intensity or both to increase total caloric
    expenditure.
  • Pedometers can also be used to target gt5,000
    steps per day.

37
The Association Between Time and Intensity
38
Type
  • Cardiovascular Exercise is best determined by
    preferences, skills, risk of injury, availability
    of facilities, and ability to initiate and
    maintain moderate level exercise.
  • Uses LARGE muscle groups for extended periods of
    time. 
  • Improves cardiovascular measures and health
    parameters
  • 1)   Oxygen consumption
  • 2)   Cardiac output, stroke volume, resting
    heart rate
  • 3)   Blood pressure control
  • 4)  Glucose tolerance
  • 5)   Increase HDL, Lower LDL

39
Type, contd
  • Choose type of cardiovascular exercise best
    suited to individual lifestyle
  • Walking programs are well accepted as an easy
    place to start that most individuals can follow,
    with only minimal requirements i.e.,
    appropriate shoes, and a time and place to walk.
  • A couple that loves ballroom dancing and dance
    once a week should be encouraged to adhere to
    this activity and increase the frequency to at
    least 3 times a week on a regular basis.
  • Hayden JA et al. Exercise therapy for treatment
    of non-specific low back pain. Cochrane Database
    of Systematic Reviews 2005, Issue 3. Art. No.
    CD000335. DOI 10.1002/14651858.CD000335.pub2.
  • Peterson J. Get moving! Physical activity
    counseling in primary care. Journal of the
    American Academy of Nurse Practitioners 2007
    19349357

40
Type, contd
  • Strength training decreases the risk of
    injury, facilitates faster weight loss/control,
    and increases basal metabolic rate (BMR).
  • Recommended at least 2 days a week to work all
    the major muscle groups (legs, hips, back, chest,
    abdomen, shoulders, and arms).
  • Type depends on risk of injury and access to
    various modalities
  • Light weights
  • Resistance bands
  • Machines
  • Free weights
  • www.cdc.gov/physicalactivity/everyone/guidelines/a
    dults.html

41
Physical Activity Resources
  • 1) Fitness Centers
  • Certified fitness professionals
  • Associations
  • Positives assists in motivation, scheduling
  • Negatives variations in quality, costs
  • 2) Books
  • Easy to find
  • Variations in quality
  • No additional external forces to assist in
    motivation
  • 3) Community groups

42
The Exercise Prescription
  • Physicians can have an enormous impact on patient
    decision to begin a physical activity program.
  • Prescription of physical activity based on the
    FITT acronym (Frequency, Intensity, Type, Time).
  • Recommendations should consider individual
    patient need, initial ability to perform physical
    activity, interest level and general health
    conditions.
  • The following principles should be conveyed
    to patients prior to embarking on a physical
    activity program.
  • Estrabrooks PA et al. Physical activity promotion
    through primary care. JAMA 2003 289 2913- 2916.
  • Chakravarthy MV et al. An obligation for primary
    care physicians to prescribe physical activity to
    sedentary patients to reduce the risk of chronic
    health conditions. MayoClinic Proc 2002 77
    165-173.

43
The Exercise Prescription
  1. Begin physical activity with light intensity
    activity, particularly if no previous exercise
    pattern gradually increase the amount and
    intensity of activity until the goal is reached.
  2. For health benefits, at least 30 minutes of
    moderate activity on most days is required.
  3. 60-90 minutes of activity per day are required
    for over-weight/obese patients, CHD and CAD
    patients (e.g., hypertension and diabetes).
  4. To encourage adherence to a lifestyle change, the
    type of physical activity should be based on
    patient preference.
  5. Remind patients to seek medical attention if
    chest pain occurs while exercising.
  6. Cardiac patients should begin an exercise program
    under supervision in a cardiac rehab center.

44
A Generic Exercise Prescription
45
Exercise Prescription Example
  • Patient A A 60 year old woman, BMI of 25, with
    no previous physical activity pattern and no
    physical limitations to exercise.
  • Goal To start an exercise program and maintain
    it.
  • Preferred activities Low-moderate intensity
    exercise (walking and gardening) 7 days per week.
  • Adapted from Warburton et al. Prescribing
    exercise as preventive therapy. CMAJ 2006 174
    961-974.

46
Exercise Prescription Example, contd
  • F Frequency 5-7 times a week
  • I Intensity Low-moderate intensity exercise
  • MHR (226-age) 220-60 160 beats/min
  • 50 - 70 of MHR 80-112 beats/min
  • Training range 80-112beats/min
  • T Type and Time Walking briskly for 30 minutes
    daily, weeding watering the garden for 30
    minutes twice a week.

47
Summary
  • It is essential for physicians to convey the
    basics of a healthful diet and the importance of
    a physically active lifestyle to patients.
  • Studies have shown that simply advising patients
    without specific assistance and follow-up is
    ineffective.
  • Only 8.2 of total outpatient visits included
    counseling or education related to exercise.
  • Intervention activities need not be
    time-consuming and can be conducted by office
    staff as well as the physician.
  • Estabrooks PA et al. Physical activity promotion
    through primary care. JAMA 2003 289 2913-2916.

48
Summary
  • Patients must be active decision-makers and set
    realistic goals.
  • Establishing specific goals and action plans
    prove most successful.
  • Counseling and follow-up are critical for
    success.
  • Intervention activities must consider the
    patients social physical environment.
    Integration with community opportunities for
    physical activity is important.
  • Balasubramanian B, et al. Practice-Level
    Approaches for Behavioral Counseling and Patient
    Health Behaviors. Am J Prev Med. 2008
    355S407-S413

49
  • The next module (Module 3) provides an overview
    of behavior modification constructs that pertain
    to lifestyle counseling efforts.
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