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.