Obesity 3.pdf

Obesity Management NUTR 344 - 2024 Outline Obesity management targets health-related improvements Management includes: 1. Dietary/nutrition intervention 2. Medical nutrition therapy 3. Physical activity 4. Behavioral approaches 5. Pharmacological agents 6. Surgery, psychotherapy (not co...

Obesity Management NUTR 344 - 2024 Outline Obesity management targets health-related improvements Management includes: 1. Dietary/nutrition intervention 2. Medical nutrition therapy 3. Physical activity 4. Behavioral approaches 5. Pharmacological agents 6. Surgery, psychotherapy (not covered in Clin 1) Readings Brown J, Clarke C, Johnson Stoklossa C, Sievenpiper J. Canadian Adult Obesity Clinical Practice Guidelines: Medical Nutrition Therapy in Obesity Management. Version 2, October 2022. Available from: https://obesitycanada.ca/guidelines/nutrition Hall KD & Kahan S. Maintenance of lost weight and long-term management of obesity. Med Clin A Am 2018; 102, 183-197. sometimes OB ppl are not coming to lose weight but abt other nutritional concerns —> important to ask permission to ask weight The more severe the stages, the worst the OB is 4Ms: can be the cause of OB 5As Guiding Principles oObesity is a chronic condition oObesity management is about improving health and well-being, not simply reducing weight on a scale oEarly intervention means addressing root causes and removing roadblocks oSuccess is different for every individual oA patient’s “best” weight may never be an “ideal” weight. Canadian Obesity Network. www.obesitynetwork.ca Key messages for health care providers oHealthy eating for all oNo single « one size fits all » eating pattern oEmphazise food quality, healthy relationship with food oGoal is to improve health outcomes (to reduce risk of chronic diseases) and quality of life oEnergy restriction is often not sustainable long-term (>12 mo) caloric restriction can have impact on neurbolic pathways —> can result in increased food intake and weight gain oIncreased risks for micronutrient deficiencies (vitamin D, B12, iron)  see Table 3 (p.18) oRefer/collaborate with RDs oFuture research should combine nutrition-related outcomes and health behaviors in addition to weight and body composition outcomes Case Study Pt MP is 65 years old male Lives with: Class 3 obesity (BMI 45.1 kg/m2 ;Height 5’5”, Weight 271 lbs) Type 2 diabetes Hypertension Knee osteoarthritis. He comes to see you in office for weight management support. ASK FOR PERMISSION FIRST: would you mind if we discuss your weight ? What are his living conditions ? Does he have family support ? Activity level ? Diet ? Eating patterns ? Self mental health awareness ? Medications ? Dietary restrictions ? Positive language, using first patient language —> remove the disease from the person (ex: person living with obesity and not you are obese) What questions would you ask Mr. MP? plot weight history and ask abt life events that impacted her weight can look at multiple factors impacting weight work management, something progressive Life Events – Weight graph https://drrobertkushner.com/3-ways-graphing-your-weight-journey-according-to-life-events-givesyou-new-insight-and-future-direction/ https://ccs.ca/app/uploads/2020/11/Portfolio_Diet_Scroll_editable_eng.pdf https://www.frontiersin.org/files/Articles/1215358/fnut-10-1215358-HTML/image_m/fnut-10-1215358-g002.jpg Metabolic improvements : blood cholesterol levels, blood glucose levels, BP Improve quality of life Increase confidence/positive body image Functionally/physical fitness Decrease risks of many diseases Physical abilities Better quality of sleep Decrease joint point Increase energy level Increase motility Improve moods What are the benefits of weight loss? Health indicators for evaluating nutrition interventions with patients/clients 2. Medical Nutrition Therapy Therapeutic objectives should be individually tailored to improve health outcomes and quality of life oChanges in eating behaviors oWeight loss / weight stabilization / prevention of weight regain oReduction in risk factors (diabetes, hyperlipidemia, hypertension, …) oReduction in complications, medications oEligibility for surgery oPsychosocial adjustment Benefits of weight loss Diabetes control ↑ Glucose tolerance ↑ Insulin sensitivity Need for glucose lowering medications even with a small weight loss (5%) Cardiovascular risk/diseases Normalizes triglyceride levels Raises HDL cholesterol Lowers LDL cholesterol Need for antihyperlipidemic Hypertension Systolic blood pressure Blood volume Cardiac output Sympathetic activity Need for antihypertensive medication medication Benefits of a 10 kg weight loss (based on Jung, RT et al, BMJ 53:307-21, 1997) Following goals that are substainable Weight loss and maintenance Weight Loss Phase Weight Maintenance Phase Diet oHypocaloric oNutrients adequate, balanced Diet continue a diet that helps them keep their new oIsocaloric vs. the new weight weight oNutrients adequate, balanced Physical activity Physical activity Behavior modification Behavior modification Estimating energy deficit for weight loss Example: sedentary man 1. (9.99 x 89 kg) + (6.25 x 170 cm) – (4.92 x 54 y) +5 = 1691 kcal/d (Energy need for resting metabolism, REE) 2. 1691 X 1.3 (PAL) = 2198 kcal/d (Total daily energy need, TEE) 3. To achieve 0.5 kg weight loss/week, subtract 500 kcal/d: 2198 kcal - 500 kcal = 1700 kcal/d Caloric equivalent of weight loss: Rule of thumb 1 lb (454 g) of adipose tissue is 87% fat = 395 g fat = 3500 kcal To lose 3500 kcal per week = - 500 kcal per day ppl living with OB will lose fat but smaller body will lose lean mass depends on PAL too Limitations: Assumes all weight loss is fat …? not the case (lean mass also loss) Lean mass is also lost to a variable extent, remember Forbes equation : depends on both the degree of weight loss and initial body fat (and +/- exercise). Loss is not linear over time  « plateau » due to ↓ REE Extreme caloric restriction = can The study shows that appetite increases by 100 kcal with every pound of weight lost due to the counter-regulatory mechanisms of hunger hormones. for ppl living with OB (Brown et al., 2020) Case Study Pt MP is 65 years old male Lives with: Class 3 obesity (BMI 45.1 kg/m2 ;Height 5’5”, Weight 271 lbs) Type 2 diabetes Hypertension Knee osteoarthritis. He comes to see you in office for weight management support. Case Study cont’d In the past, MP has followed several diets (e.g. Weight Watchers, Atkins). He tried the keto diet for a year but found it difficult to maintain. As a dieter, he has lost weight quickly (50 lbs-80 lbs) with each diet and regained it all and more when he stopped dieting. It is important to him that he does not gain more weight anymore, and that he eats a healthier diet. Energy balance Weight cycling: altering body’s requirement but your hunger increase, makes it difficult to maintain weight loss bc slower metabolism Puts the body in stress, poor relationship with food How would you help pt MP? Guiding questions: oWhat are the consequences of weight cycling? loss of motivation change in metabolism oHow would you explain weight loss and weight regain to him? Can explain it with this image: Estimating target weight oRealistic weight goal and time to achieve it. oExample: if goal is loss of 10 kg at 0.5 kg/wk  20 weeks if someone is in class III OB, can aim for higher class II OB oAim to reach healthy BMI (upper range) or oAim for more modest weight loss (5-10%) most ppl want to have a 30% weight loss —> not realistic oIf more weight is to be lost, could be stepwise: loss  stable  loss  stable “Whatever weight you can achieve while living the healthiest lifestyle you can truly enjoy” in clinical trials, can’t do it in real life (very low calories —> not sustainable) Nutrient Needs During Weight Reduction kcal PRO CHO Fat Multivitamin and mineral supplement yes < 800 ≥ 1.5 g/kg/d ≥ 50 g/d 3-6 g/d Linoleic acid 800-1200 1.2-1.5 g/kg/d 45-65% ≤ 30% kcal yes > 1200 1.0-1.2 g/kg/d 45-65% ≤ 30% kcal optional Meet DRIs: Na 1500 mg/d, K 4.7 g/d, Ca 1000 mg/d, Fe 8/18 mg/d, ≈2 L fluid High-protein diets during weight loss Systematic review of 24 trials (1063 individuals) ◦ Mean duration 12 ± 9 weeks (range 4-52 weeks) ◦ 2 groups matched for energy restriction (±300 kcal) and fat intake (≤10% difference): ◦ HP: high-protein (≥30%) SP: standard protein (<20%) prescribed Achieved macronutrient distribution HP SP protein 31% 18% carbohydrates 42% 57% fat 28% 25% (Wycherley et al. Am J Clin Nutr 2012) High-protein diets during weight loss – Results HP vs SP Greater reduction in:  Body weight (-0.79 kg difference)  Fat mass (-0.87 kg)  Serum triglycerides (-0.23 mmol/L) Less reduction in fat-free mass (0.43 kg difference) No difference in changes in:  Total cholesterol, LDL-C, HDL-C, systolic and diastolic BP, fasting glucose and insulin Less reduction in REE (4 studies only) (Wycherley et al. Am J Clin Nutr 2012) All the diets that were not high protein and low GI did induced weight gain after the weight loss period High protein low GI: a bit more weight loss with the maintenance diet, but were able to continue with the weight that they lost and that they did not regained Weight maintenance after weight loss High vs. low-protein diet N=773 adults who lost ≥ 8% of initial weight from 8 weeks of LCD (800-1000 kcal) different protein amount, but 25-30% fat Maintenance diet: ad libitum, 25-30% fat LP: low-protein (13% of E) HP: high-protein (25% of E) GI: glycemic index Weight maintenance period (Larsen et al. NEJM 2010) difficult to maintain higher intakes of protein, that’s why there’s a difference when continuing Weight maintenance after weight loss High vs. low-protein diet ≈22% protein ≈17% protein (Larsen et al. NEJM 2010) Weight maintenance after weight loss High vs. low-protein diet High vs. low protein Low vs. high glycemic index 5.4% difference in %protein intake 5 units difference in GI Less dropout Less dropout Less weight regain Less weight regain No difference in self-perceived satiety A modest increase in protein content and modest reduction in GI index favored maintenance of body weight (Larsen et al. NEJM 2010) National Weight Control Registry (1994-) o>10,000 individuals have responded oCriteria: lost 30 lbs (13.6 kg) and kept it off for ≥ 1 year o80% women, 20% men o45% on their own, 55% on formal program oAchieved methods: ◦ 10% Diet modification only ◦ 1% Physical activity only ◦ 89% Diet + physical activity modifications www.nwcr.ws National Weight Control Registry (1994-) Common features of participants: ◦ Most continue low energy, low fat diet, minimal variation ◦ 78% eat breakfast ◦ 90% exercise on average 1 hour per day ◦ 75% weigh themselves once a week ◦ 62% watch less than 10 hours TV per week isocaloric diet www.nwcr.ws The balanced diet There is no “ideal” diet for all ◦ Count calories or not, fixed menus or not, different dietary patterns … Priorities are: ◦ Increase diet quality ◦ Create energy deficit ◦ Avoid nutritional deficiencies ◦ Preserve lean mass ◦ Promote long-term adherence Change behavioral and dietary habits for life Weight loss – Key messages oA modest weight loss of 5-10% is beneficial but may not be the in a progressive weight loss bc don’t want to put strain on body and priority at a given time. ideally promote fat loss and less lean mass loss oWeight maintenance and prevention of weight regain should be considered as long term (even life-long) goals. (Canadian Clinical Practice Guidelines, CMAJ 2007) Education: Use available tools! Canada’s Food Guide https://food-guide.canada.ca/en/ USDA https://www.choosemyplate.gov Satiety Scale https://uhs.berkeley.edu/sites/default/files/wellness-hungersatietyscale.pdf 3. Physical Activity and Exercise Physical activity in Canada Physical inactivity is a major problem facing Canadians of all ages: ◦ About half of all Canadians >18 y are inactive ◦ Physically inactivity increases with increasing age ◦ More women than men are not meeting recommendations New: Total of 150 min of moderate/vigourous activities Old: Total of 150 min of moderate/vigourous activities in bouts of ≥ 10 minutes The Evidence Active adults have at least a 20-35% reduced risk of premature mortality. Modest enhancement in physical activity/fitness in previously sedentary individuals have been associated with large improvement in health status. Aerobic fitness and mortality risk Evidence-informed recommendations  If the entire Canadian population followed the current physical activity guidelines, prevention: ◦ Approx 33% of deaths from coronary artery disease ◦ Approx 25% of deaths from stroke and osteoporosis ◦ Approx 20% of deaths from colon cancer and type 2 diabetes ◦ Up to 14% of deaths from breast cancer ◦ Up to 20% of deaths from hypertension. Health benefits of physical activity Dietary Reference Intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. IN:Dietary Reference Intakes Research Synthesis Workshop Summary, Institute of Medicine of the National Academies. National Academy of Sciences, 2006. Endurance Activities  Large muscle group physical activities of a continuous nature 2 to 3 times of week Strength Training Activities Flexibility Activities Sleep: changes in hormones —> increased hunger + more time to eat https://csepguidelines.ca Only difference from the other one: challenge balance and 7 to 8 hours (not 9) https://csepguidelines.ca https://csepguidelines.ca PA and reducing caloric intake works hands in hands —> want to put emphasis on it during weight maintenance/loss Physical activity and weight loss Position stand- ACSM 2009 PA to prevent weight gain. PA of 150 to 250 min/wk with an energy equivalent of 1200 to 2000 kcal/wk will prevent weight gain greater than 3% in most adults. PA for weight loss. PA <150 min/wk promotes minimal weight loss, PA >150 min/wk results in modest weight loss of ≈2–3 kg, PA > 225–420 min/wk results in 5- to 7.5-kg weight loss, and a dose–response exists. Evidence Level A if PA = weight loss, will B need to maintain it/ increase it to maintain/ reduce weight PA for weight maintenance after weight loss. Some studies support the value of ≈200- to 300-min/wk PA during weight maintenance to reduce weight regain after weight loss, and it seems that ‘‘more is better.’’ However, there are no correctly designed, adequately powered, energy balance studies to provide evidence for the amount of PA to prevent weight regain after weight loss. B Lifestyle PA is an ambiguous term and must be carefully defined to evaluate the literature. Given this limitation, it seems lifestyle PA may be useful to counter the small energy imbalance responsible for obesity in most adults. B PA and diet restriction. PA will increase weight loss if diet restriction is modest but not if diet restriction is severe (i,e., <kcal/wk needed to meet RMR). A Resistance training (RT) for weight loss. Research evidence does not support RT as effective for weight loss with or without diet restriction. There is limited evidence that RT promotes gain or maintenance of lean mass and loss of body fat during energy restriction and there is some evidence RT improves chronic disease risk factors (i.e., HDL-C, LDL-C, insulin, blood pressure) B Physical activity in obesity management https://obesitycanada.ca/guidelines/physicalactivity Step Up and Be Counted! Get walking with a pedometer or accelerometer; Motivational tool; Helps to track progress; Benchmark for goal setting; ◦ ◦ ◦ ◦ Week 1: Find your baseline Week 2: Set realis c goals (↑20%) Track the progress Challenge your friends Daily Step Goals Group Steps Per Day Children 12,000 to 16,000 Youth Adults 11,000 to 12,000 10,000 Adults (weight loss) Older Adults 12,000 + 6,000 to 7,000 Case Study While MP owns a gym membership, he has difficulty finding time. His weight makes him feel like he will be judged at the gym. Focus on himself and his fitness journey exercise that interests him (not necessarily need to go to the gym) Need to explore why he feel insecure/why he’s scared of being judged Start easy with working out Going with friends Provide tools to start his physical fitness journey How can you help MP become more active? 4. Behavior Modifications Gradual, permanent changes in eating and exercise habits = the only way to change weight permanently Different approaches work for different people ◦ Registered Dietitians ◦ Formal weight loss programs ◦ Self-help groups ◦ Community fitness centers Behavior Modification in Weight Management First Goals: oIncrease awareness to change eating habits oIncrease physical activity oAlter attitudes oDevelop support systems oEducate about nutrition (Not weight loss on the scale) there’s other health indicators as we’ve seen Stitches December 2004/January 2005 usually after 5-10% weight loss Readiness Assessment Behavioral oAbility to eat well and increase physical activity oSuccess at previous weight loss attempts oAbility to practice self control skills Psychological oAttitudes about weight loss and changing behavior oConfidence in ability to lose weight Environmental oSocial support oLife circumstances to improve relationship with food + make better choices with snacks Enhancing Self-awareness Expanded Food Diary Food and amount Time Feeling Activity Lunch Roast beef sandwich Hot Cocoa, 1 cup 12:30 hurried Office Work Dinner Chicken Pot Pie Carrot-raisin salad Skim milk, 1 cup 7:00 relaxed T.V. 2:45 3:15 content angry Reading report Phone Calories Breakfast Skipped Snacks Candy Bar, 1 1/2 oz Coke, 12 oz Daily Calorie Total: 240 175 545 310 85 210 145 1710 Behavior chain Avoid: “DIET” = PUNISHMENT So avoid the sequence: I am “bad” to have become obese I must punish myself by dieting I can’t even do that properly I cheated, to hell with diet!  I am hopeless Path to Desirable Eating Behavior Coping Prevent Skills mistakes Long-term Increased Control Confidence can’t associate food with reward want to help the person understand permissive thought and lead to restraint thoughts Changing patient’s perspective Skill of restraint Permissive thought • “I’ve been so good with following my diet, I deserve to at this piece of cake!” Restraint thoughts • “If I eat this now, I’ll feel good for momentarily, but then I’ll feel frustrated and regretful, just as I have in the past.” cake for other occasions, not as a reward Changing patient’s perspective Skill of resilience Self-critical thoughts • “I can’t commit to my eating goal because it’s so hard to find time to cook at home. Why can others lose weight and I can’t?” guilt and frustration Resilience thoughts • “Okay, I’m being hard on myself and I don’t feel good now. This is a valuable learning opportunity. I have to work harder to manage this in the long term and finds ways to meal plan and prepare food during the weekend. I now know what action I need to take. When I eat well, I feel great and it will allow me to continue making decisions that align with my values.” Case Study cont’d MP is a truck driver and does 10h overnight trips. He usually prepares breakfast for the trip. When he's hungry, he'll go to Tim Hortons and buy a bagel, a donut, and an XL double. He found that because of his sweet tooth, he had developed a habit that is difficult to change. Prepare more food on his own Slowly substituting sweet foods for fruits that are still sweet or sweet foods that are more nutritious Donut: start choosing without glazing/filling or 1 donut instead of 2 Sweets: more space out during the day and smaller quantities Meal spacing Carry more things for his trips Diabetes: need to make sure it’s not too much and space during the day Should ask them what they think/what they are ready to do How can you help Mr. MP eat better? Summary: the balanced diet oWeight reduction diet for 6-12 months: high-protein and moderate fat within acceptable macronutrient distribution ranges of DRIs: o10-35% protein: 25-30% during weight loss, 15-20% for maintenance o45-65% carbohydrates (favor whole grains, limit added sugars) oFor some, better ≤ 30% total fat oinclude good sources of essential fatty acids olow intake of saturated and trans fatty acids oMeal replacements may be considered as components when commencing an energy-reduced diet (+ education) oThe right diet is one that the patient will follow…! (Canadian Clinical Practice Guidelines, CMAJ 2007) Food that they enjoy Not to restrict Affordable meal Balance Foods that the whole family can eat Following satiety symptom Some ppl want to record what they eat Be something that you could do happily: balance the food you enjoy + enjoy the events that you want Plan that is simple to follow Plan that doesn’t ask you to cut off categories that you love What makes an eating pattern sustainable for a client? Should go one tool at a time to not overwhelm the client Nutrition education based on behaviors oGradually modify eating habits: target diet quality oKnow portion size oDevelop skills to select healthy diets: label reading, budgeting, cooking coking workshop oManage special situations: eating out, parties oIncrease awareness of cues to eat don’t want to lower REE by skipping oAvoid hunger: no meal skipping, include snacks + protein meals oTreat yourself with tasty foods oTake time to eat, in good company Follow dietary guidelines for the Brazilian population Brazil’s 10 Steps to a Healthy Diet 1. Make natural or minimally processed foods the basis of your diet. 2. Use oils, fats, salt and sugar in small amounts. 3. Limit consumption or processed foods. 4. Avoid consumption of ultra-processed foods. 5. Eat regularly and carefully in appropriate environments and in company. 6. Shop in places that offer a variety of natural or minimally-processed foods. 7. Develop, exercise and share cooking skills. 8. Plan your time to make food and eating important in your life. 9. Out of home, prefer places that serve freshly made meals. 10. Be wary of food advertising and marketing. http://www.foodpolitics.com/wp-content/uploads/Brazilian-Dietary-Guidelines-2014.pdf 5. Pharmacological treatment Adjunct therapy to diet, exercise, behavior Evaluate benefits/risks ratio: ◦ About 5% weight loss vs. placebo ◦ Costs + side effects + mode of administration With meds: 2/3: fat loss 1/3: muscle loss Orlistat (Xenical®) Orlistat : Lipase inhibitor (oral, TID), $$ oAction: nonabsorbed inhibitor of lipase, produces malabsorption of ~30% of ingested fat, if taken before meals oEfficacy: o ~3 kg loss > placebo, for up to 4 years o 54% achieve >5% weight loss at 1 year o Improved blood pressure, lipids, glycemia fat soluble vitamins oSide effects: fatty stools, fecal urgency & incontinence, losses in vitamins A,D,E, K (must take supplements) use for ppl that binge eats/really strong cravings Naltrexone/Bupropion (Contrave®) Naltrexone hydrochloride: opioid receptor antagonist Bupropion hydrochloride: antidepressant (inhibitor of dopamine reuptake) (oral, BID), $$$  have to be given in combination oAction: induce satiety, influence reward system to reduce cravings oEfficacy: don’t have studies over 1 year o ~5% loss > placebo, at 1 year (longer-term not studied) o 48% achieve >5% weight loss at 1 year o Improved lipids, glycemia but increased blood pressure oSide effects: nausea, constipation, headache, dry mouth, dizziness, diarrhea oSeveral contraindications need to start with low doses and then increase Liraglutide (Saxenda®) Liraglutide: glucagon-like peptide (GLP-1) analog (daily subcutaneous injection), $$$$ ppl have to take it everyday oAction: ◦ acts on POMC/CART neurons to induce satiety ◦ Increase insulin and decreases glucagon during glucose elevation o Efficacy: ◦ ~4 % loss > placebo, for up to 3 years ◦ 63% achieve >5% weight loss at 1 year ◦ Improved blood pressure, lipids, glycemia + o Side effects: Nausea, constipation, diarrhea, vomiting Semaglutide (Wegovy®) Wegovy: glucagon-like peptide (GLP-1) analog (weekly subcutaneous injection), $$$$ Action: ◦ acts on POMC/CART neurons to induce satiety ◦ Increase insulin and decreases glucagon during glucose elevations History: ◦ 2018 for the management of T2DM at a dose of 0.5 mg or 1.0 mg weekly (Ozempic) ◦ 2021 for long-term obesity management at a dose of 2.4 mg weekly in people with or without type 2 diabetes. same substance than ozempic same molecule as liraglutide Efficacy: o 12.5% % loss > placebo, at 1 year (longer-term not studied) ◦ 86.4% achieve >5% weight loss at 1 year ◦ Improved blood pressure, lipids, glycemia + Side effects: ◦ Nausea, constipation, diarrhea, vomiting Case Study Cont’d MP has recently heard a lot about Liraglutide from his friend and would be interested in using this medication to promote his weight loss. discuss side effects + want to work on nutrition aspect cost importance of maintaining all the other lifestyle changes Why he wants to use it ? Pros and cons Informed decision Need to use it long term bc if stop it, weight regain What would you recommend? Main results: difference of weight of 18.4% for ppl using it and placebo during 12 weeks intensive program Semaglutide: Wegovy® (weight management) and Ozempic® (diabetes) Ppl lost 48 lbs at highest dose (type 2 diabetes) Resources https://obesitycanada.ca