OWCH O nline W eight management C ounseling program for H ealthcare 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/

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 (1kg=2.2lb). • 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, cont’dThe 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.

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, cont’d 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, cont’d 10. Limit sodium intake to < 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 >1,500 mg of sodium daily. 11. Limit alcohol intake to no >1 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/~dms/foodlab.html#see1

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 Sport’s Medicine. ACSM’s 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 60–90 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 • Borg’s 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/heartrate.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. Borg’s Rating of Perceived Exertion • Borg’s 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.” • Borg’s 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/measuring/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. • > 6 METs = vigorous-intensity physical activity.

34. METs examples

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, cont’d • 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 >5,000 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, cont’d 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; 19:349–357

40. Type, cont’d 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/adults.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 • 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. • For health benefits, at least 30 minutes of moderate activity on most days is required. • 60-90 minutes of activity per day are required for over-weight/obese patients, CHD and CAD patients (e.g., hypertension and diabetes). • To encourage adherence to a lifestyle change, the type of physical activity should be based on patient preference. • Remind patients to seek medical attention if chest pain occurs while exercising. • Cardiac patients should begin an exercise program under supervision in a cardiac rehab center.

44. Physical Activity prescription Frequency: 5 times a week Intensity: Gradually increase until 75% of maximum heart rate or until finding it difficult to converse when exercising Type: Based on personal preference Time: Gradually increase until reaching 30-90 minutes a day (based on risk) Caution: If you feel chest pain, stop immediately and return to your doctor for a check up Additional advice: Adhere to a balanced diet, combining physical activity while watching caloric intake. Substitute the stairs for an elevator; walk or ride your bike instead of driving your car. 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, cont’d • 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-upis ineffective. • Only 8.2% of total outpatient visits included counseling or education related to exercise. • Intervention activities need not be time-consumingand 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 patient’s 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; 35;5:S407-S413

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