# Presentation: 045160

## Healthy Weight Management

- Judy Simon MS, RD,CD
- University of Washington
-  Medical Center/Roosevelt Clinic

## Outline

- Obesity definition
- Prevalence
- Energy Homeostasis
- Fad Diets
- Lifelong Healthy Weight

## Obesity

- Over 50% of Americans are overweight
- One in three adults is obese. Why?
- Sedentary lifestyle
- Dietary choices
- Obsession with dieting
- Lack of time
- Stress

## Increases in Obesity Among Adults, WA and US, 1990-2000

## Body Mass Index

- Your weight in kilograms divided by the square of your height  in meters
- Kg/ m2

**BMI Categories**
- Overweight 25-30
- Obese I    30-35
- Obese II   35-40
- Obese III  >40

## Slide 6

## Epidemiology of Obesity

**Flegal KM. *****JAMA***** 2002; 288:1723-27**

## PREVALENCE OF OVERWEIGHT IN U.S.

**PREVALENCE OF OVERWEIGHT IN U.S.**

## PREVALENCE OF OBESITY IN U.S.

**PREVALENCE OF OBESITY IN U.S.**

## PREVALENCE OF OVERWEIGHT AND OBESITY IN U.S. BY RACE

**PREVALENCE OF OVERWEIGHT AND OBESITY IN U.S. BY RACE**

## PREVALENCE OF OVERWEIGHT IN CHILDREN

**PREVALENCE OF OVERWEIGHT IN CHILDREN**

## Pediatric Obesity

**Ogden CL. *****JAMA***** 2002; 288:1728-32**

## Pediatric Obesity

**Strauss RS, *****JAMA *****2001; 286:2845-48**

## WHR trumps BMI for Risk

## Obesity may cause disease directly or indirectly

- Obesity

- Disease
- (osteoarthritis)

- Disease
- (heart failure, sudden death)

- Risk Factor
- (high blood pressure,
- cholesterol, glucose)

## Genes Causing Disease May Also Cause Obesity

- Genetic Defect
- (lipid metabolism, glucose uptake, insulin responses)

- Obesity

- Disease
- (hyperlipidemia, diabetes)

## Slide 17

## Socioeconomic Contribution to Obesity-related Illness

## Which Path for the Obese?

- Weight
- Goal

- Caloric restriction
- +
- Healthier lifestyle

- Temporary wt. loss
- Euphoric attitude

- Recidivism
- Weight cycling
- Fatalistic attitude

- Prevention of further
- weight gain
- Improved health
- Positive attitude

- Weight
- Goal

- Health
- Goal

- Caloric restriction
- +
- Healthier lifestyle

- Healthier lifestyle

-  Temporary wt. loss
- Improved health
- Euphoric attitude

-  Recidivism
- Weight cycling
- Impaired health
- Fatalistic attitude

-  Focus on nutrition
- Prevention of further
-  weight gain
- Improved health
- Positive attitude

*Healthy Weight Journal 1998 *

## Want to take a walk?

## THE AVERAGE AMERICAN WALKS JUST 300 YARDS PER DAY

**THE AVERAGE AMERICAN WALKS JUST 300 YARDS PER DAY**

**Notes:**
Data analysis was done using Sudaan to account for the complex survey design.
Multiple logistic regression was used to identify the risk factors of obesity.  The variables listed here were available from the Washington State BRFSS.  
Variables were first screened in a bivariate model which included age, sex and the interaction terms.  Backward elimination was used to select the final regression model.  

## The American Weight Paradox

**Weight loss industry ($$$)**
**Weight “gain” industry ($$$$$$$$$$)**
**Cultural obsession with weight**
**Greater prevalence of dieting**
**Increasing incidence of overweight/obesity**
**Is dieting (focus on weight loss) the answer?**
**Is dieting (focus on weight loss) the problem?**

## Problems with Dieting

**Published data on (long-term) success rates indicate high recidivism**
**Dieting may increase risk for future weight gain (i.e., dieting may cause the thing it’s supposed to cure)**
**Fosters a yo-yo syndrome that undermines weight control efforts and may adversely affect health**

## Co-Morbid Conditions of Obesity

- Cardiovascular
- CAD, HTN, CHF, RHF, DVT, PE, CVA
- Respiratory
- OSA, asthma, hypoventilation syndrome
- Endocrine
- DM2, IR, IFG, IGT, dyslipidemia, PCOS, infertility, hypogonadism
- Malignancy
- Breast, colon, pancreas, prostate, uterine

- Gastrointestinal
- GERD, NASH, gallstones
- Musculoskeletal
- DJD, OA, LBP
- Genitourinary
- Incontinence, UTI
- Skin
- Venous stasis, cellulitis, panniculitis, skin infections
- Psychologic/Neurologic
- Depression, migraine, pseudotumor cerebri

**80% of people with a BMI >30 have at least one debilitating co-morbid illness**

## All-Cause Mortality and Obesity

- Mun EC, *Gastroent. *2001; 120:669-81

**Each year more than 300,000 Americans die of causes related to their obesity**

**Notes:**
Best data see Calle EE NEJM 1999, 341:1097-1105

## Weight Loss

- Decrease in blood pressure
- MacMahon S, *Eur. Heart J.* 1987; 8(Suppl B): 57-70
- Improve serum lipid profile
- 	Dengel JL, *Am. J. Clin. Nutr.* 1995; 62:715-21
- Improve glucose tolerance and decrease insulin resistance
- 		Agurs-Collins TD, *Diabetes Care.* 1997; 20:1503-11

**Effects of 5-10% decrease in body weight**

- Blackburn G. *Obes. Res.* 1995, 3 Suppl. 2:211s

**Notes:**
First Interim Summary:
Clearly we have an epidemic of obesity on our hands that is not slowing down as yet
Clearly this disease is decreasing quality of life, length of life and is very expensive
What do we need to do about it?
Clearly we need to lose some weight.
So let us identify the cause of obesity.

## Weight Loss: Physics

- Energy Out

- Body Weight

- Weight loss =

-  Energy IN
-  Energy OUT

**Notes:**
Etiology at the level of physics is very simple
At the biochemical and biological level it is very complex
At the clinical level it is currently impossible

## Why do Diets Fail?

- More than 80% of people who are actively trying to lose weight choose **Nutrition** as their only lifestyle modification

**Notes:**
Another interim summary
Energy homeostasis pathways are active in our bodies right now.
They are biased toward preventing weight loss rather than slow weight gain.
These pathways are the chief reason why some many people fail at maintaining weight loss

## National Weight Control Registry

- Since 1994
- Widely advertised (including in diet books)
- Now more than 3000 participants
- Entry criteria are a documented 30+ lbs weight loss maintained for >1 year
- Participants followed with yearly questionnaires

## Maintaining Weight Loss

- Behavioral strategies that predicted success
**Physical activity ********1 hour/day**
**Low fat/ high carbohydrate diet**
**Frequent self-monitoring of weight**

- Wing RR. *Annu Rev Nutr.* 2001;21:323-41

**Notes:**
Poor maintenance data mostly older studies changing nutrition only

## Physical Activity

- _Baseline health:_ cardiac risk factors, maximal weekly activity (PT, Cardiology, Pain clinic/Rheum)
- _Plan:_ Increase activity!
- _Goal:_ 60-90 min of low/mod activity _every_ day
- _Aids:_ Pedometer
- Involve the spouse/family
- ‘No assist’ days

**Notes:**
Increased activity confers benefits independent of weight loss
PT or exercise physiologist if available especially if special needs patient
Cardiology for EST if concerned about CAD
Pain clinic/ Rheum if joint pain is limiting
Pedometer counts steps
‘No assist’ remove motors and batteries from life, I.e. get up to change channel, take stairs, walk to desk of co worker instead of phone, walk to lunch instead of cab, park far away, take your bike, throw away electric toothbrush

## Popular Diets

- Low carbohydrate diets- fad or trend?
- Early 70’s- “no CHO” diets
- Protein sparing modified fasts
- Liquid protein diets
- Cambridge, Herbalife
- Hospital based VLCD

## Late 80’s early 1990s

- CHO “the good guys”
- Easy message
- High cho, low fat, no calorie counting

## Late 90’s	

- CHO’s... going bad
- Consumers eating CHO without considering calories
- Physical activity decreasing
- Industry introduces low-fat, no-fat foods

## Late 90’s-2004

- High CHO are bad!
- High CHO diets are fattening!
- Protein is the best fuel for the body.

## Why is low-CHO diets so popular?

- Quick weight loss
- The diet will “jump start” me into healthy eating
- Maybe this one will work

## Low-CHO Diet Plans:Focus on one nutrient

- Dr. Atkins
- Carbohydrate Addict’s Diet
- Sugar Busters
- Zone Diet
- Eat Right for Your Blood Type
- South Beach Diet

## Results of recent studies

- NEJM, 2003
- Samah et al, 348:21, 2074-81 (6 month)
- Foster et al, 348:21, 2082-90 (12 mo)

## How to respond to clients on low CHO diets

- Ask questions- find out what they are really doing and why?
- Calories count.
- Encourage less refined CHOs.
- CHOs role in health
- Exercise is important

## How to Recognize a Fad Diet

- IS the author credible?
- Diets that advocate:
- Miracle foods
- Rapid weight loss
- No exercise
- Rigid menus (good vs. bad)
- Recommendations based on single foods

## Diets Don’t Work

- 50% Americans diet annually
- 5-50% maintain significant weight loss
- Some cause significant health problems

## Strategies for Success

- How can you achieve an acceptable body weight and get off the dieting roller coaster?

## Non Diet Approaches

- DASH
- Intuitive Eating
- Mediterranean Food Pyramid
- Plate Method
- The Solution (Mellin)