Weight Control

The Secret(s) of Weight Control FAT WEIGHT REDUCTION How do we reduce? Is there a ?ideal? way? Are there rules? Weight Control Success Prognosis for success is not good! Likelihood of success in long-term maintenance of weight loss depends on level of obesity at start of intervention Benefits of Fat Loss Weight loss improves disease risk biomarkers Small changes in weight (5-10%) can yield large health gains Benefits of Fat Loss Reported benefits of weight loss for men and women Quality of life - 95% Energy level - 92% Mobility - 92% General mood - 91% Self confidence - 90% Interactions - 65% Improved job performance - 55% Body Weight Control Theories Set-Point A point that you can?t get below of above Dynamic Equilibrium Cognitive Control Set-Point Theory The Case Against Dieting Developed in 1982 by Bennett and Gurin. A control system is built into every person determining how much fat they should carry. Regular exercise seems most promising at altering set point. Dynamic Control Theory Input v Output calories in v calories out healthier foods may have different advantage than other foods, not just # of cals, still main thing but nutrition may help too Energy Balance Equation Cognitive Control Personal issues more than biology control weight Living together in fatness Change theory (BW changes do occur) How do we explain success? Components of Behavioral Therapy for Obesity Wadden and Foster. Med Clin North Am 2000:84:441. Self Monitoring Problem Solving Contingency Management Cognitive Restructuring Social Support Stress Management Stimulus Control Long-term Weight Loss is Improved with Long-term Maintenance Therapy Weight Loss (%) Perri et al. J Consult Clin Psychol 1988;56:529. 0 1 2 3 4 5 6 7 8 9 10 11 12 Time (mo) 13 14 15 16 17 P <0.05 No maintenance tx Maintenance tx Diet and behavior modification therapy National Weight Control Registry Created in 1993 by researchers at Brown University and University of Colorado. Over 4500 registrants, must have lost at least 30 pounds and kept off for a least one year. (Average member lost 60 for 5 years) What can we learn from these people? National Weight Control Registry 45% lost weight on their own 55% lost weight with the help of a program 78% eat breakfast every day 75% weigh themselves at least once a week 62% watch less than 10 hours of TV/week 90% exercise an avg. of one hour a day Review when, where, and how behaviors will be performed Identify behavior change goal Have patient keep record of behavior change Review progress at next treatment visit Five Steps to Facilitate Behavior Change Wadden and Foster. Med Clin North Am 2000;84:441. 1 2 5 3 4 Congratulate patient on successes (do not criticize shortcomings) Internet education (access to Internet resources) Internet behavior therapy (weekly online contact) Internet Technology Can Be Used to Provide Effective Behavior Therapy Weight Loss (kg) Tate et al. JAMA 2001;285:1172. Baseline 3 months 6 months P =0.005 Behavioral Treatment of Obesity in an SKIPPEDOutpatient Office Practice Provide structured, goal-oriented approach with realistic, short-term goals Frequent patient visits (initially every 1-2 weeks) to enhance compliance Long-term contact helps maintain motivation needed for long-term success Identify office staff to provide brief weigh-ins and review self-monitoring Use written educational materials and manuals PRETTY MUCH SKIPPED Responding to Nonadherence Do not take patient?s behavior personally Assume lack of planning, not motivation, is the problem Do not criticize patient (safeguard their self-esteem) Identify obstacles Determine how obstacles can be handled in the future Acknowledge the difficulty of behavior change and provide encouragement Develop a new plan and shorten interval required for success Obesity Treatment Pyramid Diet Physical Activity Lifestyle Modification Pharmacotherapy Surgery So, How Do We Lose Excess Body Fat? Strategies Nutrition Exercise Behavior Combo How Ready are You to Lose Weight? You have good intentions to lose weight, but are you mentally prepared to follow through? Take this self-assessment quiz to learn if you are really ready to start losing weight. 1. Are you motivated to make long-term lifestyle changes that require eating healthy foods and exercising more? 2. Do you currently have distractions in your life that may prevent you from committing to your weight loss program? 3. Do you truly believe that slower is better? 4. Are you realistic about your weight loss goal? 5. Do you have family and friends to support your weight loss efforts? 6. Do you believe that you can change your eating habits? 7. Are you willing to become more physically active? 8. Do you have time to keep records of your food intake and physical activity? 9. Are you willing to look at past successes and failures in weight loss and other areas of your life? 10. Do you view a healthy weight loss program as a positive experience? 11. Have you resolved any eating disorders or other emotional issues that make it difficult for you to achieve a healthy weight? 12. Do you believe that a healthy weight is a lifelong commitment? Diet Strategies For Weight Loss Restrict certain foods Limit quantity Count calories Limit %Fat intake Exchange diet Liquid formula Lowers resting metabolism Regain weight with higher % fat Psychological consequences Dieting extremes Weight Cycling (Yo-Yo Effect): Dieting The Best Weight Loss Plan Maximizing Chances for Success Psychological factors influence eating behaviors Modification of eating behaviors where, when, how Substitute behaviors (established behaviors v replacement behaviors) smaller; slowly; cook; avoid Exercise and Weight Loss What do we know? Benefits of Regular Physical Activity in Obese Persons Decreases loss of fat-free mass associated with weight loss Improves maintenance of weight loss Improves cardiovascular and metabolic health, independent of weight loss Physical Activity Helps Preserve Fat-Free Mass During Weight Loss Diet Only Loss of Fat-Free Mass (% Total Weight Loss) Diet Plus Physical Activity Men Women *P<0.05 Reprinted with permission from Int J Obes Relat Metab Disord, Ballor and Poehlman;18:35. Copyright 1994 Macmillan Publishers Ltd. Relationship Between Physical Activity and Maintenance of Weight Loss Not Maintained Subjects Exercising (%) P<0.001 Weight Loss Pattern Maintained Reprinted with permission by the American Journal of Clinical Nutrition. © Am J Clin Nutr. American Society for Clinical Nutrition. Effect of Long vs Short Bouts of Exercise on Total Amount of Activity and Weight Loss Long bout = one 40-min session. Short bout = four 10-min sessions. Activity (min/wk) Long Bouts Short Bouts Long Bouts Short Bouts 10 8 6 4 2 0 Weight Loss (kg) P=0.08 P=0.07 Jakicic et al. J Obes Relat Metab Disord 1995;19:893. Effect of Decreasing Sedentary Activities vs Increasing Physical Activities on Body Weight in Children 6-12 Years Old 0 Time (months) Decreased Sedentary Activity Change in Percent Overweight Increased Physical Activity Epstein et al. Health Psychol 1995;14:109. 4 8 12 Decreasing Television Viewing Leads to Improved Body Mass Index in Children 6-month intervention Robinson JAMA 1999;282:1561. Control Change in BMI (kg/m2) 6-month intervention Control Change in TV viewing (h/wk) P=0.002 P<0.001 Guidelines for Increasing Physical Activity Assessment 1) Medical and psychological readiness 2) Physical limitations 3) Current activities 4) Barriers to activity Develop physical activity plan Start activity slowly and gradually increase planned aerobic activity to 200 min/wk Enhance compliance Programmed vs lifestyle activity At-home vs onsite activity Multiple short bouts vs single long bout of activity Exercise and Weight Control Exercise for weight control Misconceptions about exercise Exercise and food intake (appetite control) (overhead) Caloric stress of physical activity Effectiveness of regular exercise Dose response relationship Walking-running for different durations Exercise frequency (cumulative effects) Start slowly and progress gradually Self-selected energy expenditures- mode of exercise Exercise and Weight Control The best type of physical activity for weight loss Aerobic Resistance training Dose - Response relationships Behavior changes to upset the energy balance equation Alternate activities (fidgeting) Determine when and how to make changes Dietary Changes Plus Exercise Nutrition changes plus exercise-the ideal combination Spot reduction does not work Areas of fat loss Fat is preferentially mobilized from upper body sites & deep abdominal areas as opposed to gluteal & femoral deposits Possible gender difference Men appear to respond better to weight loss interventions May be due to fat patterning Effects of Exercise and Food Restriction on BW of Rats CONCLUSIONS Animals given unlimited food but forced to exercise gained weight more slowly and had a lower final body weight then sedentary free eaters! Benefits of Adding Exercise to Diet Increases overall size of energy deficit Facilitates fat mobilization and oxidation from visceral Increases relative loss of fat by preserving FFM Blunts drop in BRM and slows weight gain Requires less reliance on kCal restriction to create deficit Contributes to long term success of weight loss efforts Provides health benefits Provides psychological benefits Provides for moderate suppression of appetite Successful Approaches to Overcoming Excess Body Fat Doing it yourself Diet books Dietary supplements and diet aids Commercial Weight-loss programs Prescription drugs Surgery Psychological help Doing It Yourself Don?t try to lose more than 0.5?2 pounds per week Combine any nutritional changes with physical activity Choose lifestyle strategies that you can maintain over the long term Diet Books Reject books that Advocate unbalanced ways of eating Claim to be based on a secret Use gimmicks Promise quick weight loss Limit the selection of foods Accept books that advocate a balanced diet plus exercise Healthy Food Plans Any diet that cuts calories can cause weight loss Low-carbohydrate diets have not been proven safe over the long-term Low-fat diets should focus on nutrient dense foods, especially whole-grains, fruits, and vegetables Diets with many restrictions have high drop-out rates Dietary Supplements and Diet Aids Dietary supplements are subject to fewer regulations than over-the-counter medications; they have not been proven safe and effective FTC: More than half of advertisements for weight-loss products make representations that are likely to be false Weight-Loss Programs Noncommercial weight-loss programs Commercial weight-loss programs Partnership for Healthy Weight Management Online weight-loss programs Clinical weight-loss programs Prescription Drugs Appetite suppressants include phentermine, diethylpropion, and sibutramine Orlistat is a drug that blocks fat absorption Prescription weight-loss drugs cause moderate weight loss, but all have risks and side effects Prescription weight-loss drugs are recommended only for people who have a BMI over 30 and who have been unable to lose weight with lifestyle changes Newest drug on the market are ?endocanniboid? drugs that block appetite and also affect fat metabolism Surgery Surgical intervention may be recommended for some people who have a BMI of 40 or higher or who are 100 or more pounds overweight Gastric bypass surgery works by creating a small stomach pouch that restricts the amount of food that can be eaten Surgery has a high rate of complications, but is improving Bariatric Surgery Indications BMI >40 kg/m2 or BMI 35?39.9 kg/m2 and life-threatening cardiopulmonary disease, severe diabetes, or lifestyle impairment Failure to achieve adequate weight loss with nonsurgical treatment Contraindications History of noncompliance with medical care Certain psychiatric illnesses: personality disorder, uncontrolled depression, suicidal ideation, substance abuse Unlikely to survive surgery NIH Consensus Development Panel. Ann Intern Med 1991;115:956. Long-term Effect of Gastric Bypass Surgery on Body Weight Poiries et al. Ann Surg 1995;222:339. BMI (kg/m2): 50 34 35 35 Weight Loss (% of Excess Weight) Years After Surgery 0 20 40 60 80 100 0 2 4 6 8 10 12 14 Complications of Bariatric Surgery Gastric bypass: Anastomotic leak with peritonitis Stomal stenosis Marginal ulcers Staple line disruption Nutrient deficiencies (iron, calcium, folic acid, vitamin B12) Dumping syndrome Small bowel obstruction Internal hernia Adhesions Long-term Survival: Canada Rel. Risk = 0.11 (.04-.27) 89% reduction in risk of death over 5 years Christou et al. Ann Surg 2004;240:416-424 % Mortality Major Obesity-related Comorbidities That Have Been Improved by Bariatric Surgery Type 2 diabetes Hypertension Obstructive sleep apnea Obesity hypoventilation GERD NALD, NASH Pseudotumor cerebri Depression Dyslipidemias Coronary artery disease Cardiac dysfunction Venous stasis disease Polycystic ovary syndrome Infertility Cancers Degenerative joint disease Quality of life