Sheri R. Colberg, PhD, FACSM - American Diabetes Association · 2017-09-30 · ADA Weight Loss Recs...

Sheri R. Colberg, PhD, FACSM

Professor Emerita, Exercise Science

Old Dominion University

Issues for Discussion America’s body weight epidemic

MNT and dietary assessment

Physical activity for weight loss

Use of behavioral strategies

Role of social support

Role of medical interventions and/or surgery

America’s Weight Epidemic

2/3 of Americans overweight, 1/3 obese

Possible causes include: Overconsumption of calories

Calorie-dense diets

“Portion distortion”

Low nutrient density

What Causes Body Fat Gain?


Physical inactivity/sedentary lifestyle

At work/school

During leisure time



Physical inactivity/sedentary lifestyle

Genetics/hereditary

A “thrifty” gene?

Altered hormones?


Balancing Calories and Activity Caloric intake > need = weight gain

Impact of Food/Calorie Intake Increased intake of sugary beverages

Intake of highly-refined, “white” foods

Inadequate fiber intake

General lack of vitamins and minerals

Impact of Sedentary Lifestyles Americans less active than ever before

Wide availability of labor-saving devices

More sedentary jobs and leisure pursuits

Most American adults fail to exercise regularly, and many do no activity at all

Youth spend less time playing outdoors, more time doing electronic games

Is Weight Loss Essential? ● Diabetes Prevention Program: weight loss most

important factor to prevent type 2 diabetes ( 58%)

● Goal of loss of 5-7% of body weight

● Every kg (2.2 lb) lost diabetes risk by 16%

Hamman RF et al. Diab. Care, 29:2102-2107, 2006

Is Weight Loss Essential? ● Lower fat intake and physical activity predicted weight

loss (5-7%), but…

● Only regular exercisers kept the weight off long-term

● Insulin action by:

● Exercise

● Dietary changes

● No wt loss needed

Hamman RF et al. Diab. Care, 29:2102-2107, 2006

MNT and Dietary Assessment

Diet Quiz #1 Which of these fad diets is likely to make you lose the most weight overall?

a. Shangri-La Diet

b. Fruit Flush Diet

c. French Women Don’t Get Fat Plan

d. Cabbage Soup Diet

e. Morning Banana Diet

f. All of these diets would work due to calorie restriction (but they’re definitely not all equally healthy)

Calories Intake: Popular Diets Diet Plan Average Daily

Calories %

Carbohydrate

%

Fat

%

Protein

Wt Watchers 1,450 56 24 20

Atkins 1,520 11 60 29

South Beach 1,340 38 39 23

Volumetrics 1,500 55 23 22

Jenny Craig 1,520 62 18 20

Zone 1,660 40 30 30

Ornish 1,520 77 6 17

Should We All Go on Diets? Weight loss

Possible to lose weight on any lower calorie diet

Slight advantage of higher protein diets

Weight regain Weight loss easier than prevention of weight regain

90-95% of dieters regain all weight (and then some) in 6-12 months after weight loss

Warning: May end up “fatter” than before dieting

National Wt. Control Registry Online database of over 10,000 adults in NWC Registry

(since 1994)

Medically documented weight loss of:

At least 30 pounds

For at least one year

80% women (averaging 45 years, 145 pounds)

20% men (49 years, 190 pounds)

http://www.nwcr.ws/Research (as of 2017)

National Wt. Control Registry Losses from 30 to 300 pounds lasting 1 to 66 years

Some losses rapid, others very slow (over 14 years)

55 percent used some type of weight loss program

Engage in more sustained (~41 minutes) moderate or vigorous exercise—like brisk walking or jogging—than overweight people that haven’t lost or kept weight off


Activity by NWCR Participants

Lessons from the NWCR Weigh in frequently (to catch backsliding early)

Exercise most day of the week

Eat a healthy breakfast

Continue to count or monitor calorie intake (logbook)

Set a weight maintenance or weight loss goal

Try to maintain dietary consistency on all days

Be aware of portion control and a balanced plate

Spend less time watching TV

Prepare and eat most meals at home


ADA Weight Loss Recs Diet, physical activity, and behavioral therapy designed to

achieve >5% weight loss should be prescribed for overweight and obese patients

Interventions should include ≥ 16 sessions in 6 months, focus on lifestyle and behavioral strategies to achieve a 500–750 kcal/day energy deficit

Diets with same caloric restriction but different protein, carbohydrate, and fat content equally effective

Am Diabetes Assoc. Diab. Care, 40(1):S57-S63, 2017

ADA Weight Loss Recs After initial weight loss, comprehensive weight

maintenance programs should:

Include at least monthly contact

Encourage ongoing monitoring of body weight (weekly or more frequently)

Continue with reduced calorie diet

Participate in high levels of physical activity (200–300 min/week)


Individualized Nutrition Plans Individualized dietary plans essential for weight loss (and

disease management)

Referral to RD for medical nutrition therapy (MNT)


Keys to Appropriate Nutrition Energy balance

Modest weight loss achievable by the combination of reduction of calorie intake and lifestyle modification

Intervention

Intervention programs to facilitate this recommended

Portion control and healthy food choices

Key for weight loss and overall health


Other Keys to a Healthy Diet

Physical Activity for Weight Loss

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Diet Quiz #2 When dieting to lose weight, what is the best way to lose bad “visceral” fat?

a. Eat fewer calories every day

b. Burn extra calories with exercise

c. Eat fewer calories and do aerobic exercise

d. Eat fewer calories and do resistance training

e. Eat fewer calories and do any type of exercise

f. All of these except for doing “a” without exercising

BMI and Physical Activity

Thompson DL et al. Med Sci Sports Exerc, 36: 911-914, 2004

Amati F et al., Diab Care, 32(8): 1547-9, 2009

Insulin Action by Age and Wt

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Why Exercise When Dieting?

Critical Role of Physical Activity Exercise prevents loss of muscle mass when dieting

Exercisers lose more body fat, especially the “bad,” visceral type of fat

Only exercisers keep the weight off and keep their metabolic risks lower (insulin action greater)

Even loss and maintenance of 5-7% of body weight has major health benefits

Possible to be “fit and fat” and healthy

Critical Role of Physical Activity Typical weight loss diet results in 3 pounds of muscle

for every 10 pounds lost

For health, muscle mass loss should not exceed 10 to 15 percent of total weight loss—no more than 1 to 1.5 pounds for every 10 lost

Physical activity prevents some loss of muscle mass on calorie-restricted diets

Aerobic Training Visceral Fat

Giannopoulou et al. J Clin Endocrinol Metab. 90:1511–1518, 2005

Ibañez et al. Diab. Care, 28:662–668, 2005

Resistance Train Visceral Fat

Scale Wt Loss May Be Slower

Use of Behavioral Strategies

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What Affects Behavior? Behavior change is a psychosocial issue

Inability to lose weight may reflect emotional/mental or social behavior

Consider assessment for symptoms of:

Diabetes distress

Depression and anxiety

Disordered eating

Limited cognitive capacity


How Is Behavior Modified? Be aware of behavioral triggers in:

Physical environment

Social environment

Personal environment

Find new ways to deal with old eating triggers

Applying Behavior Modification Goals and objectives

Commitment to lose weight

Diary of daily diet and activities and behavioral patterns

Implement behavioral changes

Setting Appropriate Goals To be successful at behavior change, set appropriate

SMART goals

Food and Activity Tracking MyPlate (ChooseMyPlate.gov and SuperTracker.gov)

MyFitnessPal

LoseIt

SparkPeople

CRON-O-Meter

FatSecret

MyNetDiary

Fitocracy Macros

CarbsControl

Monitor/measure amount of food

Plan meals

Monitor calories

Monitor fat intake

Eat at home more often

Involve others in dietary changes (social support)

Successful Dieting Behaviors

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Kruger et al. Int J Behav Nutrition Phys Activity, 3:17, 2006

Lack of time (perceived or real)

Lack of motivation/inertia

Cost, transportation to, and accessibility of

exercise training areas

Unsafe neighborhood; lack of sidewalks

Activity not culturally appropriate

Fear of falling among elderly (65+)

Physical ailments/other constraints

Lees at al. J Aging Phys Act, 13(1): 23-33, 2005

Overcome Barriers to Exercise

More spontaneous physical

activity (SPA), active leisure,

activities of daily living (ADL)

Adding in bits of activity during

the day may be easier

Fitness gains less overall, but

many health benefits

Benefits related to simply

breaking up sedentary time

Engage in More SPA Time

Add in More Daily Activity Walk or bike (not drive)

Take the stairs

Park farther away

Stand up/walk around

Work in the garden, rake leaves, or wash the car

Do housework, cleaning

Dance around the house

Play with kids/grandkids

Role of Social Support

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Medical/Surgical Interventions

Use of VLC Diets For weight loss of >5%, short-term (3-month)

interventions that use very low-calorie diets (≤800 kcal/day) and total meal replacements may be used

Carefully selected patients

Trained practitioners in medical care settings

Close medical monitoring

To maintain weight loss, such programs must incorporate long-term comprehensive weight maintenance counseling


Weight Loss Medications Weight loss (“weight-friendly”) medications used in U.S.

Orlistat (Xenical)

Phentermine

Lorcaserin (Belviq)

Qsymia (phentermine and long-acting topiramate combo)

Contrave (Naltrexone HCl/Bupropion HCl)

Liraglutide (Saxenda/Victoza)

Some diabetes meds more “weight-friendly” than others

Weight-Friendly Diabetes Meds Weight-Gain Medications Weight-Friendly or Weight-Neutral Medications Sulfonylureas Micronase, Diabeta, Glynase, Glibenclamide,

Glucotrol, Amaryl, Diamicron, Glizid, Glyloc, Reclide

Metformin Glucophage, Glumetza, Fortamet, generic metformin, Glucophage XR

Glinides (Meglitinides) Starlix, Prandin, NovoNorm

DPP-4 Inhibitors Januvia, Onglyza, Tradjenta, Nesina, Galvus

SGLT2 Inhibitors Invokana,Farxiga/Forxiga, Jardiance

Thiazolidinediones (TZDs) Actos, Avandia

GLP-1 Receptor Agonists Byetta, Bydureon, Victoza, Trulicity, Tanzeum/Eperzan, Lyxumia, Adlyxin

Longer-Acting Insulins: Humulin N, Novolin N, Humulin R, Novolin R, Lantus,

Toujeo, Basaglar

Short-Acting (before meals): NovoLog, Humalog, Apidra

Long-Acting Insulins: Levemir, Tresiba

Short-Acting (after meals): NovoLog, Humalog, Apidra

Inhaled Insulin: Afrezza Amylin Analog: Symlin

Alpha-Glucosidase Inhibitors Precose, Glucobay, Glyset

Osama and Colberg. The Diabetes Breakthrough, Harlequin, 2014

Surgical Weight Loss Options Surgical interventions

Various gastric bypass, sleeve placement, or other options

Require pre-surgery lifestyle and behavior training

Potential for:

Lower CVD risk, better quality of life, lower BMI

Adverse effects (acute post-surgical infection, dumping syndrome, anemia, osteoporosis)

Long-term nutritional and micronutrient deficiencies


Lasting weight loss is best achieved using lifestyle changes

and behavioral strategies to avoid weight regain

Weight loss is possible on any type of reduced-calorie diet

Inclusion of physical activity is critical for loss of fat

weight instead of muscle mass during dieting and for

prevention of weight regain

Behavior management is a key component of weight loss

Other medical/surgical options may be used for some

Final Conclusions

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Sheri R. Colberg, PhD, FACSM - American Diabetes Association · 2017-09-30 · ADA Weight Loss Recs...

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