Obesity Treatment: How to make a difference with your clients

1. Obesity Treatment: How to make a difference with your clients Claudette Peck, LCMHC, RD, LD Staff Nutritionist Dartmouth College Health Service

2. Obesity Trends* Among U.S. AdultsBRFSS, 1991-2002 1991 1995 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman) 2002 No Data <10% 10%–14% 15%–19% 20%–24% ≥25% cdc.gov/nccdphp/dnpa/obesity/trend

3. 2007 Obesity Map

4. What are we dealing with? 2/3 of Americans meet the criteria for overweight (BMI>25) • Risks: Combination of BMI and waist circumference • Males >40 inches • Women>35 inches • Disease risks significantly increase with combination of BMI>25,>30, >35, >40

6. Assessment Factors • Weight/BMI • Waist Circumference: Men>40 inches, Women>35 inches • Blood pressure: >130/85mm Hg • Fasting glucose: >110 mg/dL • Triglycerides: >150mg/dL HDL: Men <40mg,dL; Women <50 mg/dL • Any 3 of the above = Metabolic Syndrome • Other risks: Cigarette smoking, Age, Gender, Family History

7. Genes vs. Environment • “Genetics loads the gun—the environment pulls the trigger.”

9. Influences on Food Intake • Social pressure to eat • Holidays & Special Events • Marketing/Advertisements • Time of Day • Paired eating activities • Emotions • Others…

10. Implications for improving effectiveness of Interventions • Study by Ogden (2000) showed weight loss maintainers(>3 years of maintenance weight) when speaking of reasons for weight loss motivation, less endorsed medical reasons, more endorsed psychological consequences and indicated they had been motivated to lose weight for psychological reasons.

11. Anti-Fat Beliefs • Clear discrimination has been documented in 3 areas: education, health care and employment. • The reason for this appears to be very strong anti-fat attitudes. • For example, 28% of teachers in one study said that becoming obese is the worst thing that can happen to a person; 24% of nurses said they are 'repulsed' by obese persons; and, controlling for income and grades, parents provide less college support for their overweight children than for their thin children. Brownell, K., & Puhl, R. (2003). Stigma and Discrimination in Weight Management and Obesity, The Permanente Journal, Summer 2003/7 (3)

12. Obesity Bias: What are your beliefs? • Attitudes Toward Obese Persons scale (ATOP) • Beliefs about Obese Persons scale (BAOP) • Implicit Attitudes Test (IAT)

13. How do other providers feel about the Obese? • Primary care physicians report that key barriers to weight loss counseling are: • Self perceived low competence in treating obesity • Lack of treatment effectiveness • Poor patient motivation • Time constraints • Lack of reimbursement Befort, CA, et al (2006) Weight-Related perceptions among patients and physicians. J. Gen Intern Med, 21 (1086-1090).

14. Additionally… • In a study of 620 primary care physicians, 40% agreed that obese patients could reach a normal weight if they were motivated, but that most patients would not be motivated enough to lose a significant amount of weight. Befort, CA, et al (2006) Weight-Related perceptions among patients and physicians. J.Gen Intern Med, 21(1086-1090).

15. Motivation

16. Motivational Interviewing (MI) • MI emphasizes the identification of differences between a client’s current behavior and his/her desired goals. • MI acknowledges ambivalence and “resistance” as part of the process vs. a lack of motivation. • MI requires the helper to be reflective vs. directive. DiLillo, V., Siegfried, N.J., & West, D.S. (2003). Incorporating motivational interviewing into behavioral obesity treatment. Cognitive and Behavioral Practice, 10, 120-130.

17. Importance/Confidence Scale How important is it for you right now to change your behaviors? On a scale of 0-10 what number would you give yourself? 0…………………………………………………….10 Not at all important extremely important What would need to happen for you to go from x to y?

18. Importance/Confidence Scale If you decide to change, how confident are you that you could do it? On a scale of 0-10 what number would you give yourself? 0……………………………………………………10 Not at all confident extremely confident What would need to happen for you to go from x to y?

19. Termination Maintenance Relapse Action Contemplation Preparation Precontemplation Transtheoretical Stages of Change Prochaska, Norcross & DiClemente (1994)

20. Where to go from here… • If a client answers either question between 1-4, assume they are in pre-contemplation and consider the following steps: • Validate their experience • Acknowledge the client’s control of decision • Give your opinion on the medical benefits of weight loss • Explore concerns from the client’s view • Acknowledge possible feelings of being pressured to change • Validate that they are not ready and that it is solely their decision • State that, at this time they are not ready, but that it is possible they may feel differently at a future time. www.cellinteractive.com/ucla/physcian_ed/interview_alg.html

21. Where to go from here (con’t) • Answers between 5-7 indicate some continued ambivalence, assume clients are in contemplation. • Validate client’s experience • Restate that the decision to change is still completely their own • Clarify pros and cons of changing behavior • Leave opportunity for continued movement toward change. www.cellinteractive.com/ucla/physcian_ed/interview_alg.html

22. Where to go from here (cont’d) • If answers are between 8-10, assume they are ready to take action and help prepare them for behavior change. • Praise decision to change behavior • Identify and assist in problem solving regarding obstacles • Encourage small initial steps • Help identify social supports • Provide future follow-up appointments to assist with adherence www.cellinteractive.com/ucla/physcian_ed/interview_alg.html

23. Diets vs. Non-Diet Approach

25. Dietary Recommendations • Kcal restrictions-1200-1500/day to promote weight loss • Low carb-more weight loss in short-term; no difference in losses long-term • Meal replacements-may be helpful in LCD, may help to alter appetite expectations • Fat, Fiber, and Protein all shown to be helpful in satiety. Protein especially important in maintaining lean body tissue during weight loss • Nutrient distribution seems less important to overall kcal reduction

26. The Bottom Line… • “Reduced-calorie diets result in clinically meaningful weight loss regardless of which macronutrient they emphasize.” Sacks, F. M., Bray, G. A., Carey, V. J., et al.,(2009). Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. NEJM, 360(9), 859-873.

27. Realistic and Reasonable Goals for weight loss • 8-10% reduction in weight in first 6 months • Most weight loss occurs in first 12 weeks of program • Secondary goal: To sustain momentum and maintain weight loss

28. Discrepancies in Expectations Befort, CA, et al (2006) Weight-Related perceptions among patients and physicians. J.Gen Intern Med, 21(1086-1090).

29. Improving Adherence • “Attendance at group sessions strongly predicted weight loss…. Several recent trials have shown that continued contact with participants after weight loss is associated with less regain. These findings together point to behavioral factors rather than macronutrient metabolism as the main influences on weight loss.” Sacks, F. M., Bray, G. A., Carey, V. J., et al.,(2009). Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. NEJM, 360(9), 859-873.

30. Fit vs. Fat: Can you be both? • Overweight and obese people who are fit are less likely to die prematurely than unfit people who are lean(Lee, CD, et al., Am J Clin Nutr 1999; 69:373-380) • Highly Fit men with 2 or 3 risk factors had about the same mortality risk as Low Fit men with no risk(Blair, SN, et al., JAMA 1996; 276: 205-210) • Low Fitness is as significant a risk factor for premature death as smoking, high blood pressure, diabetes, and high blood cholesterol, regardless of weight( Barlow et al., Int J Obes Metab Disord, 19(suppl 4):41, 1995 and Wei et al., JAMA, 282: 1547, 1999)

31. Where does exercise fit into weight loss planning?

32. Physical Activity (PA) • PA prevents weight gain • PA enhances weight loss • PA is the best predictor of weight loss maintenance.*** • Ultimate goal in behavioral interventions is to promote long term adherence

33. Determining Exercise Needs • Research shows that approximately 4.5 hours of moderate intensity exercise (55-69% max HR) that results in an energy expenditure of at least 2000 calories per week, in combination with a reduced caloric intake, will produce desirable results. • Intermittent exercise (10-15 minutes sessions) that accumulate to 30-40 minutes per day, seems to be as effective as continuous sessions. • Start slowly… American College of Sports Medicine www.acsm.org

34. Lifestyle Activities • Short bout exercise (10 minute intervals of moderate activity) practiced multiple times per day; shown to have better adherence in meeting exercise goals, with similar level of fitness.

35. What works? Answers from: National Weight Control Registry • How the weight loss was accomplished: 45% of registry participants lost the weight on their own and the other 55% lost weight with the help of some type of program. • 98% of Registry participants report that they modified their food intake in some way to lose weight. • 94% increased their physical activity, with the most frequently reported form of activity being walking. • There is variety in how NWCR members keep the weight off. Most report continuing to maintain a low calorie, low fat diet and doing high levels of activity. • 78% eat breakfast every day. • 75% weigh themselves at least once a week. • 62% watch less than 10 hours of TV per week. • 90% exercise, on average, about 1 hour per day http://www.nwcr.ws/Research/default.htm

36. Behavioral Recommendations • Accountability: Food Monitoring, Weight Monitoring • SMART goals (Specific, Measurable, Appropriate, Reasonable, Timely) • Non-diet Approach • Support

37. Food Diary Name: ___________________________________ Date: ____________________Today is: Su M Tu W Th F Sa Starved Very Hungry Hungry Slightly Hungry Hunger-Fullness Scale Slightly Full Balanced Full 0 1 2 3 4 5 6 7 8 9 10 Very Full STARVED H-U-N-G-E-R COMFORT/NEUTRAL F-U-L-L-N-E-S-S STUFFED Stuffed

38. When diet and exercise aren’t enough…

39. Hebals/Medications • Medication may be indicated in cases where BMI>30, and diet, behavior and exercise are already being used. • For medication to cause weight loss, it must: Reduce energy consumption, OR Increase energy expenditure, Or Interfere with energy absorption

40. Herbal/Medication Options • No current herbal/supplement on the market appears to provide safe and effective use for weight loss. Most herbals or “natural” products are either nervous system stimulants (caffeine or other derivatives), or bulking agents (fibers). • Orlistat (Xenical) approved for long-term use (interferes with fat absorption reducing about 30% of fat consumed) Alli (over-the-counter) lower-dose Orlistat • Sibutramine (Meridia) approved for long-term use (reduces energy consumption by suppressing the appetite) Peak concentration 6-7 hours, suggest client take about 6-7 hours prior to most vulnerable eating time. Should be cautious with patients with HTN, in which monitoring should occur routinely.

41. Medication Costs/Benefits • Medication can pose a financial burden to client • With use of Orlistat or Sibutramine, studies are indicating an additional 5-10% reduction in total weight as compared to diet alone.

42. What are the surgical options? • Restrictive procedures have more flexible criteria as they are both adjustable and reversible. • Bypass surgery criteria are… • BMI>40 • OR BMI>35 with comorbidities

43. Surgical Options • Options: Restrictive—Vertical Banded Gastroplasty (VBG) and Lap Band (no malabsorption for either of these) Restricts gastric volume • Restrictive and Malabsorptive—Roux-en Y Gastric Bypass and Distal Roux-en Y Gastric Bypass (restricts gastric volume AND bypasses the duodenum and part of jejunum, causing decrease in absorption of calories) Possible Outcomes- Restrictive procedures show 15-20% loss of actual weight, Bypass procedures show 25-30% loss of actual weight. Most losses occur within first 6 months post-surgically.

44. Things that can make the difference… • Provide a receptive environment including gowns, tables, chairs, scales and cuffs that will fit this clientele • Improving adherence by nurturing the client’s motivation, assisting in developing specific behavioral changes. Develop a relationship with your client. • Understanding ambivalence and resistance when working with your client vs. judging their motives. • Be Aware of biases and attitudes • In a study done by Maiman et al., J Amer Diet Assoc., 1979… 87% of dietitians viewed the obese as “self-indulgent”, 74% attributed “family problems to the obese, and 32% indicated that obese patients “lack willpower”.

45. Case Study #1 • 43 y.o. female, single-mother of 3 children (ages 15, 13, 8), works full-time. Ht 5’4”, weight 186 lbs. Family hx of DM type II, HTN. Pre-pregnancy weight was 135 lbs, gained weight with each pregnancy, but unsuccessful in taking it off. Complains of fatigue and feeling stressed with work, home and responsibilities. States, “I know that losing weight will help me have more energy and feel better about myself, but the idea of making changes seems overwhelming at this point.” • Where do you believe she is in terms of stage of change? • What else do you need to know? • What questions will you ask? • Describe the conversation you may/may not have with her?

46. Comments/Questions?

47. Food Intake Patterns

49. References and Websites • National Institutes of Health Publication No 02-4084. The Practical Guide: Identification, Evaluation, and Treatment of overweight and obesity in adults • http://win.niddk.nih.gov/index.htm • www.obesity.org • www.eatright.org • www.consumer.gov/weightloss • www.naaso.org • www.shapeup.org

50. Resources • www.mypyramid.gov • National Institutes of Health Publication No 02-4084. The Practical Guide: Identification, Evaluation, and Treatment of overweight and obesity in adults • http://win.niddk.nih.gov/index.htm • www.obesity.org • www.eatright.org • www.consumer.gov/weightloss • www.naaso.org • www.shapeup.org. • www.nwcr.ws/Research/default.htm • www.acsm.org • www.thelifestylecompany.com/