JRO EXAM 2

Alternative, Complementary, and Integrative Therapies

CAM is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. Conventional medicine is medicine as practiced by holders of M.D. (medical doctor) or D.O. (doctor of osteopathy) degrees and by their allied health professionals, such as physical therapists, psychologists, and registered nurses. Some health care providers practice both CAM and conventional medicine. While some scientific evidence exists regarding some CAM therapies, for most there are key questions that are yet to be answered through well-designed scientific studies--questions such as whether these therapies are safe and whether they work for the diseases or medical conditions for which they are used. The list of what is considered to be CAM changes continually, as those therapies that are proven to be safe and effective become adopted into conventional health care and as new approaches to health care emerge.

Nutrition Guidelines for AN

Caloric prescription Initial weight gain Start at 30-40 kcal/kg/day (1000-1600 kcal/day) Assess risk for refeeding syndrome Controlled weight gain phase Increase prescription in small progressive increments to promote expected rate of controlled weight gain (2-3 lb/wk for inpatients and 0.5-1 lb/wk for outpatients) Up to 70-100 kcal/kg/day may be required (3000-4500 kcal) If patient requires a higher kcal prescription, evaluate for vomiting, discarding food, increased exercise, increased motor activity, increased REE/DIT Weight maintenance phase Adults: 40-60 kcal/kg/day Ongoing growth and development in children/adolescence: 40- 60 kcal/kg/day Macronutrients Protein Minimum intake=RDA in g/kg ideal body weight 15%-20% kcal High biologic value Carbohydrates 50%-55% kcal Encourage insoluble fiber for treatment of constipation Fat 30% kcal with EFA Encourage small increases in fat intake until goal can be attained Micronutrients 100% RDA multivitamin with minerals supplement without iron Avoid supplemental iron during initial phase of weight restoration, reassess need during late treatment Determine need for supplemental thiamin during course of weight restoration

Nutrition Guidelines in BN

Calorie prescription: weight maintenance If hypometabolic rate is present provide 1500-1600 kcal/day If normal metabolic rate, provide DRI for energy Monitor body weight and adjust caloric prescription for weight maintenance Avoid weight reduction diets until eating patterns and body weight are stabilized Macronutrients Protein Minimum intake=RDA in g/kg ideal body weight 15%-20% kcal High biologic value protein Macronutrients continued Carbohydrate 50%-55% kcal Encourage insoluble fiber for treatment on constipation Fat 30% kcal Provide source of essential fatty acids Micronutrients 100% RDA multivitamin with minerals supplement Note that iron -containing preparations may aggravate constipation

Dietary Composition and Adherence

Can lose weight on different diets, but you need to be adherent If you're not adherent, you won't lose weight on any diet

Composition of Diet

Carbohydrate At least 50g/day, 100g/day better Only eat protein - will use protein for energy, not muscle building Protein 0.8g/kg for >1200kcal/day 1.0g/kg for 800-1200kcal/day 1.5g/kg for <800kcal/day Fats 2010 Dietary Guidelines For Americans 20-35% of kcals from fat Less than 10% kcal from sat. fat Replace with MUFAs and PUFAs Trans fat intake as low as possible Electrolytes and Water 8 - 8oz glasses/day Doesn't have to be water, could be other liquid Vitamins and minerals Take a multivitamin Young women should take calcium and iron supplement

Dietary Strategies for Weight Loss

Carbs, protein, fat? VLCD, LCD, BDD? Ornish, Atkins, South Beach, Weight Watchers, Jenny Craig, Master Cleanse, Jimmy K, etc., etc.?

American College of Sports Medicine-Quantity and Quality of Exercisewww.acsm.org

Cardio-Respiratory: Activity=Aerobic Freq=5-3d/w Intensity=moderate-vigorous Duration=30-60min/20-60min Ex=running Strength: Activity=Resistance Freq=5=2-3d/w Intensity=2-4 sets Duration=8-12 reps Ex=lifting Flexibility: Activity=Stretching Freq=2-3d/w Intensity=2-4 times Duration=10-30seconds Ex=stretches Neuromotor: Activity=Functions Freq=2-3d/w Intensity= Duration=20-30min Ex=yoga

How Much to Eat Before?

0.5g CHO/pound of body weight 1 hour before moderately hard exercise and 2g CHO/pound of body weight 4 hours beforehand This is the equivalent of: 75g CHO one hour before (150 lb person) 300g CHO four hours before Body digests and absorbs food during exercise as long as pace is moderate Stomach shuts down during intense exercise

Exercise/ PA

Almost 100% of people able to maintain their weight loss exercise Over half of people who relapse are not exercising

Advising Patients and Working with Complementary Providers

Communication-patient preference, available therapies-allopathic and alternative Safety Efficacy Become familiar with the literature Finding an alternative provider (licensing and certification) Integrative Health Centers and Team Approaches Ask questions and discuss treatment with alternative or complementary providers

Foods to Reduce

Compare sodium in foods like soup, bread, and frozen meals-choose the foods with lower numbers Drink water instead of sugary beverages

Cautions

Consider form and source of nutrients Interaction with drugs Use appropriate consumption patterns to increase utilization Use consistently Inform health care provider Concentrated sources of nutrients so toxicity may be more likely

Types of Weight Loss Strategies

Diet Exercise Behavior Modification Drugs Surgery

Major Risk Factors

Dieting Body Image Self Esteem Perfectionism

Treatment Selection

Treatment selected is based on BMI of patient 4 "steps" of treatment Match patient's BMI to level of treatment

Initial Consultation

Use standardized interview format for obtaining information Presents various clinical observations that will help therapist identify the bio/psycho/social factors that have contributed to the onset and perpetuation of a patient's eating behavior Offers preliminary observations regarding various subtypes of eating-disordered patients and what treatment strategies are useful with the subtypes

American Heart Association

Use up at least as many calories as you take in Eat a variety of nutritious foods from all the food groups Eat less of the nutrient-poor foods

MY plate

Used for qualitative evaluation of diets

Strategies for Long-term Management

Weight Loss Program Diet Pharmacotherapy Extended Care Social Support Exercise/Physical Activity Dietary Patterns Self-regulation

Conventional Foods (whole foods)

garlic, nuts, tomatoes

Binge-eating or purging type

less recognized; a person restricts their intake as above, but also during some bouts of restriction the person has regularly engaged in binge-eating OR purging behavior (e.g. self induced vomiting, over-exercise, misuse of laxatives, diuretics or enemas).

2007 National Health Interview Survey showed

that 17.7 of population used a non-vitamin, non-mineral supplement in the last year 37.4% of adults used fish oil/omega 3 supplement in the last 30 days 37.2% of children used Echinacea and 30.5% used fish oil in the last 30 days

Recommended Dietary Allowance (RDA)-

the average daily dietary intake level that is sufficient to meet the nutrient requirement of nearly all (97 to 98 %) healthy individuals in a particular life stage and gender group

Evaluating Dietary Supplement Use

Ask Evaluate Educate Documentation

Dietary Variety

"Diets" limit variety Eat more when there's more variety: sensory-specific satiety Jelly Bean experiment Eat more when jelly beans presented in separate containers for each flavor than when they're presented as one jumbled bowl. Present class data.

Activities > 1 hour

"Hitting the Wall" = muscles run out of glycogen "Bonking"= liver runs out of glycogen Liver glycogen feeds glucose to brain Consume enough food close enough to the event to feed glucose to your brain

Calculation of Calorie Goal

(Baseline weight X 12) - 1000 = -2 lb/wk (Baseline weight X 12) - 500 = -1 lb/wk Factor of 12 estimates resting metabolic rate and very light physical activity -1000 kcal/day x 7 days = -7000 kcals (2lb/wk) -500 kcal/day x 7 days = -3500 kcals (1lb/wk))

Estimated Average Requirement (EAR)-

- a daily nutrient intake value that is estimated to meet the requirements of half of the healthy individuals in a life stage and gender group.

Facilitating self-awareness

1. Identification of emotions, sensations, thoughts 2. Identification of distorted attitudes 3. Correction or erroneous convictions by cognitive methods Practice responding to avoided experiences 5. Reinforcement of independent expression of avoided emotions and thoughts

Weight Control Registry - Reported Dietary Intake/Day

1322 Calories 29% Fat 49% Carbohydrate 19% Protein

Programmed vs. Lifestyle Activity

16 weeks on either structured activity or lifestyle + 1200kcal diet Structured lost 8.3kg Lifestyle lost 7.9kg 1 yr. follow-up Structure gained 1.6kg Lifestyle gained 0.08kg Increasing either structured or lifestyle activity can lead to weight loss, lifestyle activity is better for weight maintenance ... Weight maintenance can be achieved with either programmed or lifestyle activity Increasing daily lifestyle activities can be just as effective as a structured aerobic exercise program in maintaining long-term weight loss. In this study, obese women were randomized to 16 weeks of treatment with a behavioral therapy program and a 1200 kcal/d diet with either structured aerobic exercise (three 45-minute step aerobics classes weekly) or instructions for increasing moderate-intensity lifestyle activities by 30 minutes per day on most days of the week (e.g. walk instead of drive short distances; take stairs instead of elevators) [1]. After the 16-week treatment phase was completed, subjects attended 4 follow-up meetings (every 13 weeks) for 1 year. The figure shows that initial weight loss was similar in both groups at 16 weeks (8.3 kg in the programmed group vs 7.9 kg in the lifestyle group, P=0.08) and a trend toward better maintenance of weight loss at 68 weeks in the lifestyle activity participants than in the group that received programmed exercise (P=0.06). These findings demonstrate that education to alter lifestyle activities is a reasonable alternative to programmed exercise for obese patients.

History of Dietary Guidelines

1894-Department of Agriculture issued food guidance information 1977-First Dietary Guidelines-suggested 30% of fat calories 1980-Dietary Guidelines for Americans brochure 1985-Dietary Guidelines 1990-Congress directed revision every 5 years Current guidelines are a result of this Next guidelines due to be out in 2015

Meal Replacements

2009 ADA Position Statement Meal replacements are helpful for those trying to lose weight Meal replacements may even lead to greater weight loss than conventional diets

Weight Control Registry

2682 calories expended/week 813 calories expended in vigorous activity 28 miles walking/week 9 hours/week

How Much Weight Loss?

5-10% of body weight lost - clinically significant People often WANT to lose more Discrepancy leads to Disappointment

Fat Stores

60,000-100,000 calories stored as fat Fat can't be used exclusively for fuel - muscles need carbohydrate as well

Other Data

83 million people used CAM 354 million visits to CAM practitioners $33.9 billion out-of-pocket expenses 14.8 billion on nonvitamin, nonmineral natural products

Which Has More Sodium?

8oz gatorade-110mg 1bagel-410mg

Prevalence of Weight Loss Maintenance

About 20% of overweight individuals become successful at long-term weight loss.

Weight Loss Programs Used by NWCR Participants

About ½ received some type of help (commercial program, MD, RD) 45% reported losing the weight on their own 89% used both diet and PA Only 10% used diet alone Only 1% used exercise alone Few reported weight loss meds or surgery

Summary of the ACS Guidelines on Nutrition and Physical ActivityACS RECOMMENDATIONS FOR INDIVIDUAL CHOICES

Achieve and maintain a healthy weight throughout life Achieve and maintain a healthy weight throughout life Avoid excess weight gain at all ages. For those who are overweight or obese, losing even a small amount of weight has health benefits and is a good place to start Get regular physical activity and limit intake of high-calorie foods and drinks as keys to help maintain a healthy weight

Family Therapy

Acknowledges that every family has issues that are difficult to deal with, and that the family can work together to help overcome these issues. As a part of a person's recovery from an eating disorder, it can be useful to address issues in the family context such as conflict or tension between members, communication problems, difficulty expressing feelings, substance abuse or physical or sexual abuse. Used with younger eating disordered clients who are still in close contact with family unit

CAM Therapies Included in the 2007 NHIS

Acupuncture* Ayurveda* Biofeedback* Chelation therapy* Chiropractic or osteopathic manipulation* Deep breathing exercises Energy healing therapy/Reiki* Guided imagery Homeopathic treatment Diet-based therapies Atkins diet Macrobiotic diet Ornish diet Pritikin diet South Beach diet Vegetarian diet Zone diet Energy healing therapy/Reiki* Guided imagery Homeopathic treatment Hypnosis* Massage* Meditation Movement therapies Alexander technique Feldenkrais Pilates Trager psychophysical integration Natural products (nonvitamin and nonmineral, such as herbs and other products from plants, enzymes, etc.) Naturopathy* Progressive relaxation Qi gong Tai chi Traditional healers* Botanica Curandero Espiritista Hierbero or Yerbera Native American healer/Medicine man Shaman Sobador Yoga

Fuel for Exercise

Aerobic vs. Anaerobic metabolism Intensity, duration, and type of activity determine fuel source used for exercise Anaerobic ATP-CP: Sprints - 5-6 seconds Anaerobic glycolysis: 6 seconds - 2 minutes Aerobic metabolism - TCA/Krebs cycle, oxidative phosphorylation: longer events, >3 minutes Aerobic - Need oxygen to metabolize fuel Anaerobic - Do not need oxygen to metabolize fuel CR=creatine phosphate

Ethnic Differences in Weight Loss

African Americans lose less weight than whites Social/environmental issues? Motivation (eg. Body image differences?) Cultural appropriateness of program? Other factors?

Reason for Revisions

American Diabetes Association has updated its nutrition recommendations. Medical nutrition therapy is essential to help people with diabetes accomplish the goals of achieving and maintaining Blood glucose close to or at the normal range A lipid and lipoprotein profile that reduces risk for vascular disease Blood pressure close to or at the normal range

Antioxidants as Supplements

An antioxidant is a chemical compound that protects cells against the effects of free radicals (molecules produced when the body breaks down food or is exposed to pollutants such as tobacco smoke or radiation). Free radicals can damage cells and may play a role in heart disease, cancer, and other medical conditions

What is an eating disorder?

An eating disorder is a dangerous mental illness, not a lifestyle choice, a diet gone wrong or a fad. An eating disorder is characterized when eating, exercise and body weight/shape become an unhealthy preoccupation of someone's life. There are a variety of eating disorders that can affect a person, with different characteristics and causes. However in general, eating disorder cases can be linked to low self esteem and an attempt to deal with underlying psychological issues through practicing an unhealthy relationship with food. A common misconception regarding eating disorders is that they are a fad, a diet gone wrong, or an attention-seeking attempt. This could not be further from the truth as eating disorders are serious, and in some cases fatal mental illnesses which often require psychological and/or physical intervention to promote recovery. It is not uncommon for a person to progress from one eating disorder to another, for example somebody with Anorexia Nervosa may later develop Bulimia Nervosa or Binge Eating Disorder, and vice versa.

Behavioral Effects BED

An overwhelming sense of lack of control regarding eating behavior Eating more rapidly than normal Periods of uncontrolled, impulsive or continuous eating whereby a person may consume many thousands of calories, often to the point of feeling uncomfortably full Eating when not physically hungry Repeated episodes of binge eating which often results in feelings of shame or guilt Eating in secret Avoiding social situations, particularly those involving food. Eating 'normal' quantities in social settings, and gorging when alone

Sources of Fuel: Intensity

Anaerobic activity (high intensity) Glucose from stored glycogen Used 18-19x's faster anaerobically vs. aerobically Anaerobic and aerobic (moderate intensity) Muscle glycogen, blood glucose, fatty acids Aerobic (low intensity) Greater proportion of fuel mix is fat vs. carb

Anorexia Nervosa

Anorexia Nervosa is characterized by low body weight and body image distortion with an obsessive fear of gaining weight which manifests itself through depriving the body of food. It often coincides with increased levels of exercise. Anorexia Nervosa is usually developed during adolescence. Anorexia Nervosa is the most fatal of all psychiatric illnesses. Extreme food restriction can lead to starvation, malnutrition and a dangerously low body weight - all of which are synonymous with a host of health problems, and in some cases death.

Nutrition Therapy

Assess nutrition status Address food and nutrition issues And associated behaviors Monitor response to treatment Implement nutrition component Provide ongoing support

Applications of DRIs

Assessment of individual nutrient intakes Assessment of group nutrient intakes Planning for individual nutrient intakes Planning for group nutrient intakes

Recovery Electrolytes

Be mindful of Potassium and Sodium No special foods necessary Less salt you eat, the less you lose in sweat Potential sodium losses in 2 hr workout=1000-2000 mg

ACS Continued

Be physically active Adults: Get at least 150 minutes of moderate intensity or 75 minutes of vigorous intensity activity each week (or a combination of these), preferably spread throughout the week Children and teens: Get at least 1 hour of moderate or vigorous intensity activity each day, with vigorous activity on at least 3 days each week Limit sedentary behavior such as sitting, lying down, watching TV, and other forms of screen-based entertainment Doing some physical activity above usual activities, no matter what one's level of activity, can have many health benefits

Common Antioxidants

Beta-carotene Lutein Lycopene Selenium Vitamin A Vitamin C Vitamin E All can be obtained as supplements but food sources are still the best option as research related to disease prevention and level needed are still unclear

Binge Eating Disorder

Binge Eating Disorder is a psychological illness characterized by frequently eating excessive amounts of food, often when not hungry. Binges represent a distraction that allows a person to avoid thinking about the real root of their problems. Feelings of guilt, disgust and depression often follow a bingeing episode. Binge Eating Disorder is characterized by an absence of purging, despite suffering similar feelings of intense guilt, shame and self-hatred after binges. While a lack of purging is evident, a person experiencing Binge Eating Disorder will often participate in sporadic fasts and repetitive diets in response to the negative sensations which follow a binge episode. Binge Eating Disorder can affect anybody, regardless of age, gender or ethnicity. In fact, research suggests equal percentages of males and females experience Binge Eating Disorder. Body weight may vary from normal to mild, moderate, or severe obesity

Why Is It Difficult to Maintain Lost Weight?

Biological Factors: Prehistoric genes Decreased energy needs Decreased metabolic rate Environmental Factors Constant exposure to high calorie food Barriers to maintaining exercise Psychological Factors Unrealistic expectations Failure to achieve initial goal

Summary: Sources of Fuel for Exercise

Both glucose (glycogen) and fatty acids are used to fuel exercise The proportion of each is dependent on the intensity, duration and fitness (i.e., training) of the athlete.

Food Composition Tables

Bowes & Church's Food Values of Portions Commonly Used Nutritive Value of American Foods, Agriculture Handbook No. 456 Composition of Foods, Agriculture Handbook No. 8 Nutritive Value of Foods, Home and Garden Bulletin No. 72 Nutrient computer data bases-Food Processor, Foodworks, etc. Data us based on food composition books

Sample Carb Loading Menu

Breakfast: 1 c orange juice ½ c grapenuts 1 banana 1 c 1% milk 1 english muffin 1 tbsp jelly Lunch: 2 slices oatmeal bread 3 oz turkey breast 8 oz apple juice 1 c frozen yogurt Dinner: 3 c spaghetti 1 c tomato sauce 2 oz ground turkey ¼ loaf multigrain bread Snack: 1 c vanilla yogurt 6 fig bars 3300 calories; 75% CHO (610 g), 15% protein; 10% fat

Dietary Patterns

Breakfast: 78% of those in NWCR eat breakfast daily 4% never eat breakfast (25% in general public) Typical: fruit and cereal

Bulimia Nervosa

Bulimia Nervosa is a serious psychiatric illness characterized by recurrent binge-eating episodes (the consumption of abnormally large amounts of food in a relatively short period of time), followed by compensatory behavior (purging or overexercising). Binge episodes are associated with a sense of loss of control and immediately followed by feelings of guilt and shame, which leads the person to compensatory behavior (purging) such as self-induced vomiting, fasting, overexercising and/or the misuse of laxatives, enemas or diuretics. A person with Bulimia Nervosa usually maintains an average weight, or may be slightly above or below average weight for height Bulimia Nervosa often starts with weight-loss dieting in the 'pursuit for thinness'. The resulting food deprivation and inadequate nutrition can trigger what is, in effect, a starvation reaction - an overriding urge to eat. Once the person gives in to this urge, the desire to eat is uncontrollable, leading to a substantial binge on whatever food is available - often foods with high fat and sugar content, which is followed by compensatory behaviors. A repeat of weight-loss dieting often follows, perhaps even more strictly - which leads to a frantic binge/purge/exercise cycle which becomes more compulsive and uncontrollable overtime.

Behavioral Warning Signs

Constant or repetitive dieting (eg. counting calories, skipping meals, fasting, avoidance of certain food groups or types such as meat or dairy, replacing meals with fluids) Evidence of binge eating (eg. disappearance of large amounts of food from the cupboard or fridge, candy or other wrappers appearing in bin, hoarding of food in preparation for bingeing) Evidence of vomiting or laxative abuse (eg. frequent trips to the bathroom during or shortly after meals) Excessive or compulsive exercise patterns (eg. exercising even when injured, or in bad weather, refusal to interrupt exercise for any reason; insistence on performing a certain number of repetitions of exercises, exhibiting distress if unable to exercise) Making lists of 'good' and 'bad' foods Changes in food preferences (eg. refusing to eat certain foods, claiming to dislike foods previously enjoyed, sudden interest in 'healthy eating') Development of patterns or obsessive rituals around food preparation and eating (eg. insisting meals must always be at a certain time; only using a certain knife; only drinking out of a certain cup) Avoidance of all social situations involving food Frequent avoidance of eating meals by giving excuses (eg. claiming they have already eaten or have an intolerance/allergy to particular foods) Behaviors focused around food preparation and planning (eg. shopping for food, planning, preparing and cooking meals for others but not consuming meals themselves; taking control of the family meals; reading cookbooks, recipes, nutritional guides) Strong focus on body shape and weight (eg. interest in weight-loss websites, dieting tips in books and magazines, images of thin people) Development of repetitive or obsessive body checking behaviors (eg. pinching waist or wrists, repeated weighing of self, excessive time spent looking in mirrors) Social withdrawal or isolation from friends, including avoidance of previously enjoyed activities Change in clothing style, such as wearing baggy clothes Deceptive behavior around food, such as secretly throwing food out, eating in secret (often only noticed due to many wrappers or food containers found in the bin) or lying about amount or type of food consumed Eating very slowly (eg. eating with teaspoons, cutting food into small pieces and eating one at a time, rearranging food on plate) Continual denial of hunger

Energy Bars

Convenient Portable Promote pre-exercise eating Promote eating during endurance exercise Claim to be highly digestible Some are low in fat (rapid digestibility) Some are high in fat Expensive

Social Factors

Cultural value placed on 'thinness' as an inextricable part of beauty Current cultural emphasis on the need for a 'perfect body' Valuing of people according to outward appearance and not inner qualities Media and popular culture's portrayal of men and women's shapes and bodies that are not representative of 'real' men and women Pressure to achieve and succeed Professions with an emphasis on body shape and size (eg. dancers, models, athletes)

Daily Weighing

Daily weighing may be an important component of weight maintenance Weight Control Registry: 75% weigh themselves at least weekly 44% of these people weigh themselves daily

Benefits of Exercise Even Without Weight Loss

Decreased visceral fat Decreased waist circumference Increased muscle mass Increased CVD fitness Increased insulin sensitivity

Using an Exchange List

Determine calorie, carbohydrate, protein and fat allowances. Determine the number of exchanges in the daily meal plan required to provide calories and nutrients. Assign exchanges to a meal or snack keeping the individual's typical eating pattern in mind. If used with an insulin dependent diabetic, the carbohydrate provided at various meals and snacks needs to be matched to the availability of insulin from injections.

What are Dietary Supplements

Dietary supplements were defined by the Dietary Supplement Health and Education Act (DSHEA) of 1994 which is an amendment to the 1938 Federal Food, Drug, and Cosmetic Act. A dietary supplement must meet all the following conditions: It is a product (other than tobacco) intended to supplement the diet, which contain one or more of the following: vitamins, minerals, herbs or other botanicals, amino acids, or any combination of the above ingredients It is intended to be taken in tablet, capsule, powder, softgel, gelcap, or liquid form It is not represented for use as a conventional food or as a sole item of a meal or the diet It is labeled as being a dietary supplement

Psychological Effects BN

Difficulties with activities which involve food Loneliness due to self-imposed isolation and a reluctance to develop personal relationships Deceptive behaviors relating to food Fear of the disapproval of others if the illness becomes known Mood swings, changes in personality, emotional outbursts or depression Self harm, substance abuse or suicide attempts Overly sensitive to references about weight or appearance Guilt, self disgust, self loathing Anxiety Depression

Psychological Effects BED

Difficulties with activities which involve food which may lead to self-imposed isolation Low self esteem and embarrassment over physical appearance Feeling extremely distressed, upset and anxious during and after a binge episode Fear of the disapproval of others Self harm or suicide attempts Overly sensitive to references about weight or appearance Guilt, self disgust, self loathing Anxiety Depression

Psychological Effects

Distorted body image Self-evaluation based largely or entirely in terms of weight and appearance Pre-occupation or obsessive thoughts about food and weight Refusal to accept that one's weight is dangerously low despite warnings from family, friends and/or health professionals Low self esteem Mood swings Clinical depression Withdrawal from interpersonal relationships in favor of social isolation

Obtaining Weight Loss Advice

Doctors - Advised 69% of overweight or obese patients to lose weight MI more powerful Barriers Time, training, reimbursement issues Registered Dietitians Insurance only covers a few conditions Self help Not well studied

Caffeine Before Exercise

Don't overdo it - can cause dehydration or electrolyte imbalance when used in excess Not magic - more CNS effects (makes exercise feel easier) than actual physiological effects Still banned by the NCAA and monitored by WADA

Drug Therapy

Drug treatment may be used to treat hormonal or chemical imbalances. In the treatment of eating disorders, anti-depressants belonging to the Selective Serotonin Reuptake Inhibitor (SSRI) group such as Zoloft, Prozac, Aropax and Paxil are commonly prescribed. Research suggests that anti-depressants such as Prozac are useful in suppressing the binge/purge cycle, particularly for people with Bulimia Nervosa. For people experiencing Anorexia Nervosa, they may be useful in stabilizing weight recovery. The effectiveness of drug treatment increases when combined with other forms of therapy such as Cognitive Behavioral Therapy. Anti-depressant medications have been found to be useful for treating some instances of depression and anxiety that may accompany an eating disorder.

Physical Effects

Dry skin Dry or chapped lips Poor circulation resulting in pins and needles and/or purple extremities Headaches Brittle fingernails Bruising easily Frail appearance Endocrine disorder leading to cessation of periods in girls (amenorrhea) Decreased libido; impotence in males Reduced metabolism Abnormally slow heart rate Low blood pressure Hypotension Hypothermia Anemia (iron deficiency) Abdominal pain Edema (retention of fluid giving a "puffy" appearance) Stunting of height and growth Fainting Abnormality of mineral and electrolyte levels Thinning of the hair Lanugo (growth of fine hair layer all over the body to promote warmth) Constantly feeling cold Zinc deficiency Reduction in white blood cell count Reduced immune system function Pallid complexion and sunken eyes Reduction of bone density which results in dry and brittle bones Constipation and diarrhea Tooth decay

Using DRIsfor Assess Groups

EARs used to examine the prevalence of inadequate intakes AI used to evaluate the mean intake of a group The UL used to estimate the percent of a population potentially at risk of adverse effects of toxicity Acceptable macronutrient distribution range is used.

Pre-Exercise Meal/Snack Guidelines

Eat a balanced, high CHO diet on a daily basis If you exercise for >60-90 minutes with no access to food; choose slowly digested CHO foods Limit high fat proteins Be cautious about sugary foods Allow enough time for food to digest

ACS Continued..

Eat a healthy diet, with an emphasis on plant foods Choose foods and drinks in amounts that help you get to and maintain a healthy weight Limit how much processed meat and red meat you eat Eat at least 2½ cups of vegetables and fruits each day Choose whole grains instead of refined grain products If you drink alcohol, limit your intake Drink no more than 1 drink per day for women or 2 per day for men

Risk Reduction With Weight Loss

Effects of 9kg weight loss: Cholesterol (-10mg): risk down 10% HDL (+3mg/dl): risk down 6% blood pressure (-5mmHg): risk down 15% Total CVD risk factor reduction: risk down 31%

Food Insecurity

Eliminate very low food security among children Reduce household food insecurity and in doing so reduce hunger

Sensitive to Volume

Energy density down, down calories, maintain volume Fruits and Veggies leads to lowest energy density

Integrative Modalities

Energy medicine Acupuncture Herbal medicine Spiritual healing Electromagnetic therapy Pet therapy Qigong Feldenkrais Zen therapy Nutrition biotherapy Behavioral interventions Massage Body work-yoga, reiki, pilates Mind-body-biofeedback, meditation, imaging, hypnotherapy Detoxification

Energy Medicine

Energy therapies involve manipulation of various energy fields for health Such fields may be characterized as veritable (measurable) or putative (yet to be measured). Practices based on veritable forms of energy include those involving electromagnetic fields (e.g., magnet therapy and light therapy). Practices based on putative energy fields (also called biofields) generally reflect the concept that human beings are infused with subtle forms of energy; qi gong, Reiki, and healing touch are examples of such practices.

Balancing Calories

Enjoy your food, but eat less Avoid oversized portions

National Center for Complementary and Alternative Medicine-NIH

Established in 1994 - $3.5M 2013 - $120.7M Clearinghouse for research studies Public information Database

Behavioral Effects

Excessive exercise and/or food restriction Secretive behavior surrounding eating or exercise Overly sensitive to references about weight or appearance Obsessive interest in cooking or preparing food for others Refusal to eat in the presence of others Aggressive when forced to eat "forbidden foods" Self harm Substance abuse Suicide attempts About 40 per cent of people with Anorexia Nervosa will later develop Bulimia Nervosa.

Eating During Exercise

Exercise >60-90 minutes: Need fluid to replace sweat losses Food to maintain energy and blood sugar levels Sports drinks containing 6-8% CHO have been shown to improve performance in events over 1 hour 100-250 calories/hour (30-60g CHO/hour) after 1st hour CHO can be liquid or solid; sugar can work DURING exercise; experiment with what your stomach can stand

For Weight Maintenance . . .

Exercise at high levels Eat low-cal, low-fat diet Eat breakfast Self-monitor frequently Maintain consistent eating pattern Prevent large regains!

Fluid During Exercise

Exercise can blunt thirst 1 pound weight loss = 2 cups fluid consumed 8 oz every 15-20 minutes Consume enough to maintain preexercise weight Some controversy between thirst vs prescribed amounts of water Children's core temps rise faster than adults - must drink! Symptoms of dehydration: Muscle cramps Nausea, vomiting Headache, dizziness Confusion, disorientation Weakness, reduced performance Inability to concentrate Irrational behavior

Predisposing factors for GI distress . . .

Exercise intensity - more intense worse Precompetition food intake - avoid high fat Fiber - avoid too much fiber Caffeine - avoid too much caffeine Gels and concentrated sugar solutions - can cause problems for some people Level of hydration - proper hydration is important Hormonal changes during exercise - may be worse for women

Relationship Between Physical Activity and Maintenance of Weight Loss

Exercise is the most important predictor of keeping off weight once you've lost it. Relationship between physical activity and maintenance of weight loss Although increasing physical activity may not improve short-term weight loss, physical activity may be very important for long-term weight management. However, most long-term (>10 months) prospective randomized controlled trials have not demonstrated a statistically significant beneficial effect of exercise on body weight, when data were analyzed on an intention-to-treat basis [1,2]. The failure to detect a beneficial effect of exercise on body weight may be related to poor compliance with an exercise program. However, large cross-sectional case studies and retrospective analyses of prospective trials found that successful long-term (>1 y) weight loss was associated with participation in regular exercise [3-6]. This figure shows data from one study that found 90% of formerly obese women who achieved and maintained average weight exercised regularly, compared with 34% of obese women who regained weight after successful weight loss (P<0.001) [3].

Weight Loss By Diet or Exercise Alone

Exercise: kcal/day: -873 weight: -4 body fat: -4.1 Diet: kcal/day: -1429 weight: -7.2 body fat: -5.9 Control: kcal/day: -433 weight: .6 body fat: -.3

Office of Dietary Supplements-NIH

Explore potential role of dietary supplements Promote research Advise CDC, FDA, NIH Defined as plant extracts, enzymes, vitamins, minerals, and hormonal products that are available without prescription Evaluate role in health outcomes improvement Budget 120.9 M in 2013 (latest data on website) Website: http://ods.od.nih.gov/

Extended Care

Extended Care: Effects of Length of Treatment on Weight Loss... Longer the treatment duration, longer weight loss is maintained 2 Groups Both received behavioral weight loss intervention for 20 weeks One group then stopped treatment, while the other continued for an additional 20 weeks Group receiving 40 weeks of treatment lost more weight and maintained weight loss

Food, Drug and Cosmetic Act

FDA regulates both fortified food and dietary supplements in accordance with the Food Drug and Cosmetic Act. Conventional foods include fortified foods and require a Nutrition Facts label Dietary supplements are a separate category of food and require a Supplement Fact panel on the label

Consultation Continued

Family and patient should be interviewed separately Give feedback to patient and family together. Should include diagnosis, prognosis, and outline of treatment plan Final moments: Need signal from patient as to what they are willing to do.

FDA Approved Weight Loss Drugs

Fat Blockers Xenical (orlistat, Alli) - gastric lipase inhibitor which inhibits the absorption of 30% of dietary fat. Produces 10% weight loss in 6-12 months with 8% weight loss at two years with continuation of the drug Appetite Suppressant Phentermine (Adipex P, diethylpropion, phendimetrazine) Phentermine and topiramate (Qsymia) Lorcaserin (Belviq)

Choose Your Foods: Exchange Lists for Diabetes Sixth Edition, 2008

First edition Diabetic Exchange lists in 1950, textbook has fifth edition which was in 2003 Exchange lists are foods listed together because they are alike. Each serving of food has about the same amount of carbohydrate, fat, protein and calories as other foods on that list. Thus, any food on the list can be "exchanged" or traded or substituted for any other food on the same list.

Carbohydrate Loading

For endurance events lasting more than 90 minutes 1. CHO "Load" Daily Daily diet should be 55-65% CHO with moderate-low fat Too much CHO is not better (target 4 g/pound of body weight/day) 2. Taper training (this is variable depending on type and duration of event) Final hard workout 3 weeks before Taper for 2 weeks before 30% of normal Little exercise 7-10 (10-13) days before 3. Eat enough protein .6-.7 g/pound 4. Don't fat load 20-25% calories Trade fat for CHO to carb load 5. Don't forget fiber 6. Plan meal times carefully 7. Drink extra fluid - 4-8 extra glasses water/juice during 2 days before event - Limit alcohol - Drink 3 glasses of water up to 2 hours before the race; 1-2 cups 5-10 min before race 8. Eat breakfast on race day 9. Be sensible about your choices

Key Guidelines for Adults

For substantial health benefits, adults should do at least 150 minutes a week of moderate-intensity or 75 minutes a week of vigorous intensity aerobic exercise. Episodes should be at least10 minutes duration throughout the week For additional and more extensive health benefits, adult should increase their aerobic physical activity to 300 minutes a week of moderate intensity or 150 minutes a week of vigorous intensity activity Muscle-strengthening activities that are moderate or high intensity and involve all major muscle groups on 2 or more days a week provide additional health benefits

Dietary Reference IntakesHistorical Overview

Formerly Recommended Dietary Allowances First published in 1941 until 1989 Primary goal was to prevent diseases caused by nutrient deficiencies Established and used to evaluate and plan menus that would meet the nutrient requirements of groups Used to interpret food consumption records of populations Used to establish standards for food assistance programs Used to establish guidelines for nutrition labeling

Fortified Foods

Fortification is the addition of nutrients to foods, including beverages, and is used synonymously with enrichment. FDA interpreted the food law and determined that fortification should not be required as nonenriched counterparts still exist. FDA does regulate how much of which nutrients must be added to enriched foods.

Modified foods

Fortified: ca in orange juice. ionized salt. Enriched: folate enriched bread Enhanced: Energy bars, snacks, yogurts, teas, bottled water, and other functional foods formulated with bioactive components such as lutein, fish oils, ginkgo biloba, St John's wort, saw palmetto, and/or assorted amino acids

Home Exercise vs. Group Exercise

Review by van der Bij et al. found: Both are effective at increasing exercise participation in short-term Long-term participation dropped for both styles of exercise

Behavioral Effects BN

Frequent trips to the bathroom, especially after eating. The length of time taken for these bathroom trips can depend on the amount of food consumed and the need felt by the sufferer to purge themselves of it. Food avoidance, dieting behavior. This may occur due to a fear of gaining weight (as in Anorexia Nervosa) and it may also be to avoid the unpleasant ritual of purging afterwards. Fluctuations in weight Erratic behavior Mood swings

Hi GI Foods

Glucose: 100 Corn Flakes: 92 Baked Potatos: 85 Gatorade: 78-89 Rice Cakes: 78 Jelly Beans: 78 Whole wheat bread: 71 Oatmeal:66 Powerade:65 Sweet Potato:59 Banana (overripe):52 Candy Bar (milk chocolate):43 Apple:38 Fruit yogurt:33 Milk (whole):27 Grapefruit:25 (GI)

Eating Before Exercise

Go by your gut Adverse GI reactions occur in 30-50% of endurance athletes Predisposing factors: Type of sport - running worse than biking Training status - more fit fewer problems Age - younger worse than older Gender - women worse than men Emotional and mental stress = GI problems

Cognitive Techniques

Goal: Normalization of eating behavior and physical condition and assessment and modification of misconceptions in self-concept deficiencies, perfectionism, separation fears and disturbed relationships Reasoning errors 1. Dichotomous reasoning: good vs bad 2. Personalization and self-reference 3. Superstitious thinking 4. Magnification 5. Selective abstraction:thinness=self-worth 6. Overgeneralization 7. Underlying assumptions 8. Self concept deficit Self-esteem - attribution on one's own value or worth Self awareness - ability to identify and accurately respond to inner experiences

Cognitive Behavioral Therapy

Goals: Changes eating habits Decreases levels of anxiety and depression Lessening the intensity of dysfunctional attitudes

Quality of Dietary Supplements

Good Manufacturing Practices published in 2007, all companies by June 2010 Manufacturers are responsible for meeting quality standards Independent organizations offer programS that evaluate supplement quality but the manufacturer pays for this service. Examples: U.S. Pharmacopeia ConsumerLab.com NSF International

Daily Food PlanBased on 2000 kcal/day

Grains, cereal: 6 serving Vegetables: 2 1/2 cup Fruits:2c Dairy:3c Protein: 5.5 oz Oils: 6 tsps Extra Fat: 260 kcal

DASH Food PlanBased on 2000 kcal/day

Grains, cereal: 7-8 serving Vegetables: 4-5 serve Fruits: 4-5 serve milk, nonfat/lowfat: 2-3 serve Meats, fish: less than 2 Nuts, seeds, legumes: .5-1 serve Fats and oils: 2-3 serve Sweets: 5/w

Therapeutic Lifestyle ChangeDiet Plan for 2000 kcal

Grains/bread: 7 serve Veg/dried beans: 5 Fruits: 4 Dairy: 2-3 Eggs: less than 2 yolks Meat, fish, poultry: less/equal to 5 oz Fats: 6 Consider stanols and soluble fiber

Healthy Eating Index

HEI is a measure of diet quality as specified by Federal dietary guidance. The food group standards are based on the 2005 Dietary Guidelines for Americans. found in MyPyramid The standards were created using a density approach, that is, they are expressed as a percent of calories or per 1,000 calories.

Use of Dietary Guidelines

Have been very consistent over the years with some notable changes based on emerging science They are the go-to document for public nutrition guidance Basis of Supplemental Nutrition Assistance Program (SNAP) which is the old food stamp program, school lunch and WIC Guidelines never tested for anything. Estimated that 3% of US population follows guidelines. There is a need to educate people on how they can fit the guidelines into their lives. Some information proposes that 2015 may be difference

Nutrition Education

Impact of malnutrition on growth and development Impact of malnutrition on behavior Set-point theory Metabolic adaptation to dieting Restrained eating and disinhibition Causes of bingeing and purging What does "weight gain" mean: fluid, lean body mass, adipose Impact of exercise on caloric expenditure Ineffectiveness of vomiting, laxatives, and diuretics in long-term weight control Portion control Food exchange system Social dining and holiday eating Food Guides Hunger and satiety cues Interpreting food labels Nutrition misinformation

Healthy People 2010 Nutrition and Weight Status Objectives

Healthier Food Access Increase the number of States with nutrition standards for foods and beverages provided to preschool-aged children in child care Increase the proportion of schools that offer nutritious foods and beverages outside of school meals Increase the number of States that have State-level policies that incentivize food retail outlets to provide foods that are encouraged by the Dietary Guidelines for Americans Increase the proportion of American who have access to a food retail outlet that sells a variety of foods that are encouraged by the Dietary Guidelines for Americans.

What are Herbal Supplements

Herbal supplements are a type of dietary supplement that contains herbs, either singly or in mixtures. An herb (also called a botanical) is a plant or plant part used for scent, flavor, and/or therapeutic properties. See NCCAM website: http://nccam.nih.gov/ "Herbs at a Glance"

VLCDs

High protein, low carbohydrate 12 week modified fast 12 weeks gradual refeeding Medically monitored Exercise included Goal - Increase initial weight loss

Hyponatremia

Hyponatremia is a dangerous condition that occurs when TOO MUCH fluid is consumed resulting in a dilution of blood sodium concentration. It can cause brain damage, seizures and death. More likely to occur in recreational runners who take a long time to finish a race.

Interpersonal Therapy

IPT focuses on interpersonal difficulties in the person's life which are considered to be the basis of the eating disorder. Generally, therapy involves three phases including the identification of interpersonal difficulties, the development of a contract to work on several specific issues and the assessment of changes The therapy is usually medium term (16-20 weeks).

Eating After Exercise

If you exercise 3-4 times/week: Muscle stores will recover with normal diet Recovery fluid: Weigh yourself before and after exercise to determine how much fluid you lose Evaluate urine color - should be color of pale lemonade Recovery CHO: Consume CHO-rich foods (moderate to high GI) within 30 minutes after finishing 1.0-1.5g/kg CHO at 2 hour intervals up to 6 hours 150 pound (68.2kg) person= 68-102g CHO or 270-400kcals Fluids OK Protein (5-9g/100g CHO) helps activate glycogen storage, and repair muscles Chocolate milk - "perfect" recovery food

Evaluating Dietary Supplement Research

In evaluating study design, is the study preliminary? Was there a control group? Was the research population large enough? Was the study long enough? Was there objective reporting of information? Were the findings supported by other published research-why or why not? Were both efficacy and safety shown? Were the study findings put into a context that makes the results relevant to clinical practice? Was the research peer-reviewed before publication? Was the study performed with animals or human beings? What was the funding source?

Use of Complemenary Therapies [NCCAM and NCHS's National Health Interview Survey, 2007]

In the United States, 38% of adults are using some form of CAM. When megavitamin therapy and prayer specifically for health reasons are included in the definition of CAM, that number rises. Approximately 12% of children use some form of CAM. Overall, CAM use is greater by: Women than men People with higher educational levels People with higher incomes

Web BasediREACH Results

InPerson Group - lost 8.0kg Internet Group - lost 5.5kg Hybrid Group - lost 6.0kg No difference between groups for those losing 5% of BW Over 50% of participants in each group Internet treatment may be more cost effective Some of the highest internet program losses to date Internet more cost effective because participant time costs of travel and travel costs in general must be taken into account for in-person groups

Sources of Fuel: Duration

Increase duration, lower intensity=Increase fat use, but not necessarily increased calorie use. Don't be FOOLED! Fat can not be metabolized unless carbohydrate is available - Glycogen and glucose are limiting factors !!

Weight Status

Increase proportion of adults who are at a healthy weight Reduce the proportion of adults who are obese Reduce the proportion of children and adolescents who are considered obese Prevent inappropriate weight gain in youth and adults

Food and Nutrition Consumption

Increase the contribution of fruits to the diets of the population aged 2 years and older Increase the variety and contribution of vegetables to the diet of the population aged 2 years and older Increase the contribution of whole grains to the diets of the population aged 2 years and older Reduce consumption of calories from solid fats and added sugars in the population aged 2 years and older Reduce consumption of saturated fat in the population aged 2 years and older Reduce consumption of sodium in the population aged 2 years and older Increase consumption of calcium in the population 2 years and older

Health Care and Worksite Settings

Increase the proportion of primary care physicians who regularly assess body mass index (BMI) of their patients Increase the proportion of physician office visits that include counseling or education related to nutrition or weight Increase the proportion of worksites that offer nutrition or weight management classes or counseling

Foods and Nutrients to Increase

Increase vegetable and fruit intake Eat a variety of vegetables, especially dark-green, red and orange vegetables and beans and peas Consume at least half of all grains as whole grains. Increased whole-grain intake by replacing refined grains with whole grains Increase intake of fat-free or low-fat milk and milk products, such as milk, yogurt, cheese or fortified soy beverages Choose a variety of protein foods, which include seafood, lean meat and poultry, eggs, beans and peas, soy products, and unsalted nuts and seeds Increase the amount and variety of seafood consumed by choosing seafood in place of some meat and poultry Replace protein foods that are higher in solid fats with choices that are lower in solid fats and kcal and/or are sources of oils Use oils to replace solid fats where possible Choose foods that provide more potassium, dietary fiber, calcium, and vitamin D, which are nutrients of concern in American diets. These foods include vegetables, fruits, whole grains, and milk and milk products.

Dietary Approaches to Stop Hypertension (DASH)

Rich in fruits, vegetables, low-fat dairy, and nuts Low in sodium, total fat, and saturated fat Adequate in calories for weight maintenance

Psychological Warning Signs

Increased preoccupation with body shape, weight and appearance Intense fear of gaining weight Constant preoccupation with food or with activities relating to food Extreme body dissatisfaction/ negative body image Distorted body image (eg. complaining of being/feeling/looking fat when actually a healthy weight or underweight) Heightened sensitivity to comments or criticism about body shape or weight, eating or exercise habits Heightened anxiety around meal times Depression or anxiety Moodiness or irritability Low self-esteem (eg. feeling worthless, feelings of shame, guilt or self-loathing) Rigid 'black and white' thinking (viewing everything as either 'good' or 'bad') Feelings of life being 'out of control' Feelings of being unable to control behaviors around food Fear of growing up/taking on adult responsibility

Social Support

Individual vs. Group Support For Obesity At both 6 and 18 months group therapy produced greater weight losses than individual therapy

Foods for Special Dietary Use

Infant foods Hypoallergenic foods such as gluten-free foods, lactose-free foods Weight-loss foods

Treatment Setting

Inpatient-hospital or treatment center, patients generally acutely medically unwell and have severe symptoms Outpatient-seen by a team of health professionals from many different disciplines, or they may see a solo practitioner like a dietitian, a psychologist or a psychiatrist Daypatient-provide a structured day with supervised or supported meals and eating, along with ongoing therapy during the daytime, up to five days a week, while allowing the individual to live at home and benefit from family interaction overnight and on weekends

Treatment

Interdisciplinary team approach Focus on psychiatric management Emotional support Extensive counseling Outpatient... inpatient hospitalization Cognitive-behavioral therapy Pharmacological agents

Position Statement of ADA

It is the position of the American Dietetic Association that the best nutrition-based strategy for promoting optimal health and reducing the risk of chronic disease is to wisely choose a wide variety of foods. Additional nutrients from supplements can help some people meet their nutrition needs as specified by science-based nutrition standards such as the Dietary Reference Intakes. JADA 2009;109:2073. This only refers to nutrient supplements

Labeling of Dietary Supplements

Labels can bear health claims (reducing risk or disease or condition), nutrient content claims (amounts of nutrients) and structure/function claims FDA does not approve structure/function claims but manufacturers must provide the text to FDA within 30 days of marketing a product Structure/function claims must bear the label that FDA has not evaluated the product and the product is not intended to diagnose, treat, cure or prevent any disease.

Rate of Weight Loss

Largest weight loss in first 2 weeks; large amount of water lost 1 pound lost is part lean and part fat 75% fat, 25% muscle Rate of loss should be 1-2 pounds/week; 1% initial weight/week Is 50 pounds in the next few weeks realistic?

Different Level BMI/treatments

Level 1 (BMI less than/equal 27): Step 1=self-directed diet and exercise, physician counseling Level 2 (BMI 27-29): Step 2=Self-help/commercial program, behvr. program Level 3 (BMI 30-39): Step 3=Low cal diet, pharmacotherapy Level 4 (BMI greater than or equal to 40): Step 4=Bariatric Surgury ....may need more or less intense therapy (step) for specific indv

External Factors

Life events, particularly those involving major changes (eg. loss of a family member or friend, the divorce or separation of parents, moving schools or jobs) Dieting Peer pressure Inability to effectively deal with stress, whereby a person lacks adequate stress-management strategies Personal or family history of obesity, depression, substance abuse or eating disorders Troubled personal or family relationships Sexual or physical abuse History of teasing or bullying, particularly when based on weight or shape

Bottom Line: People Need to Be Ready to Change

Lifestyle change is long-term Not a pill Not losing 50 pounds in a few weeks Attitude is everything You have to want to change

Long vs. Short Exercise Bouts

Long or short bouts of exercise can lead to increased activity and health benefits. ... Both those in the long and short bout groups increased their number of steps post intervention. Study was on a group of 60 inactive women. Study ran for 8 weeks. The LB and SB groups lost some weight whereas the control group gained weight.

Behavioral Therapy vs. Drugs

Lose most weight at 6 months no matter what you do. People do regain weight, but not all of their weight. The periodic weight loss interupts the cycle of gaining 2#/year People are close to maintaining a clinically significant weight loss

Self-Help/Commercial Programs

Low cost compared to academic medical centers Can work well

Psychological Factors

Low self-esteem Feelings of inadequacy Incidence of depression or anxiety Fear of the responsibility of adulthood A belief that love from family & friends is dependent on high achievement Poor communication between family members, or the reluctance of parents to allow appropriate degrees of independence as children mature Difficulty expressing emotions and feelings, particularly 'negative' emotions such as anger, sadness, anxiety or fear Ineffective coping strategies Perfectionism Fear or avoidance of conflict Competitiveness Impulsive or obsessive behaviors A need to please others Highly concerned with the opinions of others Prone to extremes, such as 'black and white' thinking

Dietary Energy Density

Lower energy-density diet = more food, fewer calories Lowest energy-density foods . . . fr/veg

Foods to Increase

Make half your plate fruits and vegetables Make at least half your grains whole grains Switch to fat-free or low-fat (1%) milk

Safety of Dietary Supplements

Manufacturers are responsible for ensuring product safety. Vitamins and minerals are presumed to be safe based on history of use. For new products, manufacturers must notify FDA of intention to market the product and provide safety information. Safety is monitored by FDA through adverse event reports from consumers, manufacturers and health professionals. Adverse events include death, a life-threatening experience, inpatient hospitalization, persistent disability, congenital anomaly, or a surgical intervention to prevent one of the above. Mandatory reporting required after 2007

Fortification and Supplementation

May provide greater food security, example: health status of WIC participants Sedentary people and low energy intake Optimal intakes may be higher than previously thought May assist in subpopulations, examples: WIC recipients, oral contraceptive users, pregnant women, elderly Individualized needs due to genetics or disease

Sequence of Treatment

May vary with eating disorder AN clients may need to be brought to a level of nutritional status before working on psychological issues AN clients may not be in control of their food intake but rather it will be left to the team of professionals Once AN client is able to think clearly, psychological issues can be addressed BN and BE clients need to establish a regular pattern of eating which will foster a decrease in binging or in the case of BN clients binging and purging Once regular eating occurs, psychological issues can be addressed Typically other types of eating disorders are treated similarly to the eating disorder they are most closely related to

self-regulation

Mean Weight Change by Consistency of Self-Monitoring: People are more successful at maintaining weight loss when they consistently engage in self-monitoring, i.e. food journaling, weighing themselves, etc.

Team Approach-Professionals

Medical doctor provides physical health management Psychiatrist, psychologist, mental health counselor provides therapy, counseling, and psychological intervention Dietitian provides nutritional assessment, eating plans, and nutritional education. Dietitians are vital in the process of nutritional rehabilitation and the development of healthy eating patterns. They work with the person with the eating disorder to identify fears of food, and discuss the consequences of not eating well. They also work with the individual to recognize feelings of physical hunger and fullness and a healthy response to these.

Pretreatment Assessments

Medical risks and history Weight and weight loss history Family history of obesity Weight loss goals and expectations Eating and exercise behaviors Social and psychological factors Motivational readiness

Mindfulness Based Therapy

Mindfulness based therapies have in common an emphasis on the practice of mindful meditation, mindful eating, yoga and a range of other techniques, aimed at increasing awareness and acceptance of eating behavior and the self. Unlike CBT, the aim of mindfulness is 'letting go' or disengaging with negative thoughts, rather than learning to challenge them. Mindfulness based therapies have in common an emphasis on the practice of mindful meditation, mindful eating, yoga and a range of other techniques, aimed at increasing awareness and acceptance of eating behavior and the self. Unlike CBT, the aim of mindfulness is 'letting go' or disengaging with negative thoughts, rather than learning to challenge them.

Calories Available as Stored Glucose and Glycogen*

Muscle glycogen: 1400 cals Liver glycogen: 320 cals Blood glucose: 80 cals total: 1800 cals

Main Uses of CAM

Musculoskeletal-lower back pain, neck pain Head and chest colds Anxiety and stress

Use of Dietary Supplements

NHANES 1999-2000 showed that 52% of adults reported taking a dietary supplement in the past month NHANES 2003-2006 showed that 33% reported taking a multivitamin/mineral supplement Those using supplements most were women, older adults, non-Hispanic whites, those with more than a high-school education, people with good health and under- and normal-weight people NHANES 1999-2004 reported that 34% of children and adolescents took some type of supplement USGAO, consumers are not well-informed about safety and efficacy of dietary supplements and have difficulty interpreting labels. Multivitamin and Public Health workshop published a peer-reviewed statement advising adults to take a daily multivitamin/mineral supplement. JADA 2005; 105:460. Use by elderly of nonvitamin, nonmineral dietary supplements is increasing. Most frequently used is glucosamine followed by ginkgo biloba, chondroitin and garlic. Women showed a linear trend over time for black cohash, borage, evening primrose, flaxseed oil, chondroitin, dehydroepiandrosterone, garlic, ginkgo biloba, glucosamine, grapeseed extract, hawthorn, and St. John's wort Men showed a linear trend over time for alpha lipoic acid, gingko biloba and grapeseed extract. Over-the-counter and prescription drugs with supplements may cause significant interactions.

Which Dietary Strategies Work for Maintenance?

National Weight Control Registry: 87.6% restrict certain foods 44% limit quantities 43% count calories 25% count fat grams 20% used liquid formula 22% use exchange system diet Variable EXCEPT that almost all used a form of diet + PA

Natural Products

Natural products in CAM use substances found in nature, such as herbs, foods, and vitamins. Some examples include dietary supplements, herbal products (botanicals), and probiotics

Fortification Policy

Nonenforceable Suggest rational addition of nutrients by adding nutrients to correct dietary insufficiencies; restoring nutrients lost during storage, handling and processing; adding 5% of Daily Reference Value or Reference Daily Intake per 100 kcal for full range of nutrients

Uses of Supplementation and Fortification

Only 3-4% of Americans adhere to the Dietary Guidelines for Americans Nutrient supplementation can impact a person's total nutrient intake as can conventional and fortified foods For nutrients of concern, multivitamin/mineral supplements increase intakes of vitamin A, vitamin E, vitamin B-6, and zinc, however, they do not have as much influence on Ca, Mg, and K.

Run Away With These . . .

Our body uses a mix of fuel sources for exercise Drink for thirst, but make sure to rehydrate after exercise CHO is the most important nutrient to monitor before and during exericse Combine CHO and protein for post-exercise recovery Pay attention to electrolytes

Pre-Exercise Snack Guidelines

Try liquid meals if you have a touchy stomach Eat well the day before if you can't eat that morning Don't try anything new before a competition Drink enough fluid

Policing Commercial Diets

Partnership for Healthy Weight Management Formed in 1999 - Voluntary Must disclose Staff qualifications Components of program Risks associated with overweight/obesity Risks associated with the program Program costs

Nutrition Therapy - AN

Restore patient's weight to 90% of expected Cessation of weight loss Improvement in eating behaviors Slow progression of weight gain and kcal Vitamin and mineral supplements Supervise meals Closely monitor serum electrolytes

When to Support Use

People restricting energy for weight loss Pregnant women Older adults Food insecure Alcohol dependent Strict vegetarians Those with increased needs due to a health condition or the chronic use of a medication that effects the absorption, metabolism or excretion of nutrients

National Weight Control Registry

People who have: Lost 30 pounds AND Maintained loss for 1 year Average Registry Stats 66 lb. weight loss Maintained for 5.5 years Calorie intake= 1409 % calories from fat=24

Pharmacotherapy

Percent Weight Loss Maintained Year 1 to Year 2 placebo: 70% Orlistat (60mg): 80% Orlistat (120mg): 80%

DSM-5 Anorexia Nervosa

Persistent restriction of energy intake leading to significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory, and physical health). Either an intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain (even though significantly low weight). Disturbance in the way one's body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. Subtypes: Restricting type Binge-eating/purging type

Benefits of Lifestyle Modification in the Pharmacological Treatment of Obesity

Pharmacotherapy + lifestyle modification helped people maintain weight losses more than lifestyle modification or drugs alone

Weight Maintenance With High Protein or High Carb Diet

Phase 1 was a Very Low Calorie Diet for 3 months Phase 2 - Divided participants up into high carb diet and high protein diet for 12 months, saw who maintained the most of the initial weight loss. Both groups gained back about 3-4 kg of the initial 17ish kg they had lost. Diets were isocaloric. Found that there was not a significant difference in weight loss maintenance between the two types of diet. Did have very low attrition rates though, only 47% of subjects remained in the study for the entire time.

Medical Foods

Phenylketonuria (PKU) formulas free of phenylalanine

Other DSM-5 Eating Disorders

Pica Rumination Disorder Avoidant/Restrictive Food Intake Disorder (ARFID) Other Specified Feeding or Eating Disorder (OSFED) Unspecified Feeding or Eating Disorder (UFED)

Contraindications to Weight Loss

Pregnancy Terminal illness Cancer Eating disorders Alcoholism, drug abuse Psychosis, serious psych problems (if unstable) Gallstones Osteoporosis

Dietary Guidelines for Americans 2010: Balancing Calories to Manage Weight

Prevent and/or reduce overweight and obesity through improved eating and physical activity behaviors Control total calorie intake to manage body weight. For people who are overweight or obese, this will mean consuming fewer calories from foods and beverages Increase physical activity and reduce time spent in sedentary behaviors Maintain appropriate calorie balance during each stage of life-childhood, adolescence, adulthood, pregnancy and breastfeeding, and older age

2008 Physical Activity Guidelines for Americans

Primary audiences are policymakers and health professionals Designed to provide information and guidance on the types and amounts of physical activity that provide substantial health benefits Regular exercise over months and years can produce long-term health benefits but need to be done each week

Dietary Reference Intakes (DRI)Today

Primary goal was to not only prevent nutrient deficiencies but also reduce the risk of chronic diseases such as osteoporosis, cancer, and cardiovascular disease Are reference values that are quantitative estimates of nutrient intakes to be used for planning and assessing diets for healthy people DRIs contain 4 categories of recommendations

Resistance Exercise

Protein needs met through average American diet (1.2-2g/kg/day) 5-6g/kg CHO per day recommended Calorie intake needs to be adequate to spare protein for muscle building 20-30% calories from fat is adequate

Acceptable Macronutrient Distribution Ranges

Protein: 10-30% Carbohydrate: 45-65% Fat: 20-35% Alpha Linolenic acid (omega-3): 0.6-1.2% Linolenic acid (omega 6): 5-10%

Meal Replacements + Money

Providing meal replacements in addition to SBT was even more effective than providing incentives in addition to SBT.

Using DRIs to Assess Individuals

RDAs used to estimate nutrient adequacy of individual diets AI used to estimate nutrient adequacy of individual diets when RDA not available UL used to estimate the potential risk of adverse effect of toxicity in individuals EARs estimate energy needs of individuals Acceptable Macronutrient Distributions can be compared to individual intakes

Best Time to Eat

Race 8 am High CHO dinner; drink extra water day before Morning (6-6:30 am): 200-400 kcal meal 10 am event High CHO dinner; drink extra water day before Eat familiar breakfast by 7 am 2 pm event High CHO dinner; drink extra water day before Big high CHO breakfast or brunch by 10 am 8 pm event High CHO breakfast and lunch Dinner by 5 pm Extra fluids all day All day event (100 mile bike ride, etc) Two days before, cut back on exercise Day before eat CHO rich bfast, lunch, dinner Drink extra fluid Light breakfast 60-90 minutes eat CHO-based foods; drink fluids

Recommended nutrient content of a weight-reducing diet

Recommended nutrient content of a weight-reducing diet Dietary guidelines proposed by the National Institutes of Health [1] recommend a 500 kcal/d deficit for overweight persons (BMI 25.0-29.9 kg/m2) who have obesity-related complications, and for persons with class I obesity (BMI 30-34.9 kg/m2). This energy deficit will result in approximately a 1-lb (0.45 kg) weight loss per week and about a 10% weight reduction at 6 months. A 500-1000 kcal/d deficit is recommended for those with class II (BMI 35.0-39.9 kg/m2) or class III (BMI 40 kg/m2) obesity, which will produce about a 1- to 2-lb weight loss per week and a 10% weight loss at 6 months. The recommended macronutrient composition for a low-calorie weight loss diet is shown in this figure and includes 55% or more of daily calories from carbohydrates, 15% from protein, and 30% or less from fat. In addition, specific recommendations are made regarding the composition of fat ingestion: total energy intake should be comprised of 8%-10% calories from saturated fat, 10% or less calories from polyunsaturated fats, and 15% or less calories from monounsaturated fats. Daily cholesterol intake should not exceed 300 mg/d, and daily fiber intake should be between 20-30 g/d. National Institutes of Health, National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults - The Evidence Report. Obes Res. 1998;6(suppl 2):51S-209S.

DSM-5 Binge Eating Disorder

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances. A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating). The binge eating episodes are associated with three or more of the following: eating much more rapidly than normal eating until feeling uncomfortably full eating large amounts of food when not feeling physically hungry eating alone because of feeling embarrassed by how much one is eating feeling disgusted with oneself, depressed or very guilty afterward Marked distress regarding binge eating is present Binge eating occurs, on average, at least once a week for three months Binge eating not associated with the recurrent use of inappropriate compensatory behaviors as in Bulimia Nervosa and does not occur exclusively during the course of Bulimia Nervosa, or Anorexia Nervosa methods to compensate for overeating, such as self-induced vomiting.

DSM-5 Bulimia Nervosa

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances. A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating). Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months. Self-evaluation is unduly influenced by body shape and weight. The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

Nutrition Therapy - BN

Reduce binge/purge cycle Normalize eating patterns Regular meals and snacks Provide order to mealtimes Food intake sufficient to prevent hunger Inclusion of "forbidden" or "feared" foods Education and support

Foods and Food Components to Reduce

Reduce daily sodium intake to less than 2,300 mg and further reduce intake to 1,500 mg among persons who are 51 and older and those of any age who are African American or have hypertension, diabetes, or chronic kidney disease Consume <10% of calories from saturated fatty acids by replacing them with monounsaturated and polyunsaturated fatty acids Consume <300 mg per day of dietary cholesterol Keep trans fatty acid consumption as low as possible by limiting foods that contain synthetic sources of trans fats, such as partially hydrogenated oils, and by limiting other solid fats Reduce the intake of calories from solid fats and added sugars Limit the consumption of foods that contain refined grains, especially refined grain foods that contain solid fats, added sugars, and sodium If alcohol is consumed, it should be consumed in moderation -up to one drink per day for women and two drinks per day for men-and only by adults of legal drinking age

Iron Deficiency

Reduce iron deficiency among children and females of childbearing age Reduce iron deficiency among pregnant females

Common Treatments

Reduced Calorie Diet Increased Exercise Behavior Modification

National Weight Control Registry...

Registry of >5,000 successful weight loss maintainers (initiated in 1994) 18 years and older Entry criteria: Must have lost at least 30 lb. and kept it off at least 1 year Questionnaires assess their weight-loss and weight-maintenance strategies

Major Research Findings on the Health Benefits of Physical Activity

Regular physical activity reduces the risk of many adverse health outcomes Some physical activity is better than none For most health outcomes, additional benefits occur as the amount of physical activity increases through higher intensity, greater frequency, and/or longer duration Most health benefits occur with at least 150 minutes a week of moderate intensity physical activity, such as brisk walking. Additional benefits occur with more physical activity Both aerobic (endurance) and muscle-strengthening (resistance) physical activity are beneficial Health benefits occur for children and adolescents, young and middle-aged adults, older adults, and those in every studied racial and ethnic group The health benefits of physical activity occur for people with disabilities The benefits of physical activity far outweigh the possibility of adverse outcomes

Sources of Information on Weight Maintenance

Research studies National Weight Control Registry

Physiological/ Biological Factors

Scientists are currently researching possible biochemical and biological factors and their role in the development of eating disorders. Research has indicated that in some people with eating disorders there is an imbalance of certain chemicals in the brain Adolescence and the associated physical, hormonal and neural changes Genetic or familial factors, for example a person who is exposed to a parent or sibling with an eating disorder is at a higher risk of developing an eating disorder themselves. While no conclusive outcome has been reached, research has provided evidence that in some cases this is due to genetic predisposition - rather than just learned behavior

Building Healthy Eating Patterns

Select an eating pattern that meets nutrient needs over time at an appropriate calorie level Account for all foods and beverages consumed and assess how they fit within a total healthy eating pattern Follow food safety recommendation when preparing and eating foods to reduce the risk of foodborne illnesses

Behavior Modification Techniques

Self-monitoring Stimulus control Assertiveness Training Problem Solving Social Support Goal setting/contingency management Eating in Social Situations Nutrition Education Relapse Prevention Self monitoring is the other big predictor of losing weight and keeping it off Stimulus Control - out of sight out of mind Problem solving - regrouping Social support - people do better in group vs. individual treatment

Over-the-counter Drugs

Sensa-maltodextrin, tricalcium phosphate, silica, natural and artificial flavors, has soy and milk ingredients. Taste and smell sensations linked to brain sensations and a feeling of fullness results. Raspberry ketones-proposed to increase thermogenesis and oxidizes fat more efficiently. These are approved by FDA as dietary supplements

Athletes and Salt

Suggested intake ~2400 mg/day Lose salt when you perspire heavily If active, have normal/low blood pressure and no family history of HTN - no need to restrict Body generally adapts to sodium imbalances If you need salt you will crave it If exercising for >4-6 hours in the heat, consume salt

Support Groups

Support groups differ from therapy groups in that they are intended to offer mutual support, increased understanding and information. Support groups are generally open in attendance (people can attend as often as they wish) and meet on a regular basis. Generally, support groups are not run by professionals, but by people who have had experience with the issue, either personally or indirectly.

Refeeding Syndrome

Severe shifts in fluid and electrolyte levels, especially phosphate, from extracellular to intracellular spaces in severely malnourished patients who have total body phosphorus depletion and are undergoing refeeding whether orally, enterally or parenterally. Refeeding syndrome consists of cardiovascular, neurologic, and hematologic complications and can be associated with significant morbidity and mortality Hypophosphatemia emphasizes need for medical monitoring and slow refeeding in AN Minimum 4-day weight gain criterion between 0.36 kg and 0.55 kg was associated with few complications in refeeding

Improving Exercise Adherence

Short vs. long bouts Short can improve adherence to exercise Group vs. home-based Both effective Lifestyle vs. structured Lifestyle - getting 30 min. of moderate activity in a way that works for you Structured - going to the gym with a trainer Both were effective in increasing physical fitness Lifestyle group maintained gains

What Kind of Carbohydrate?

Simple vs. complex? Glycemic index High glycemic index foods after exercise enhance muscle glycogen replenishment Equivocal evidence on whether low or high GI foods are more beneficial before exercise

Spinal manipulation

Spinal manipulation is practiced by health care professionals such as chiropractors, osteopathic physicians, naturopathic physicians, physical therapists, and some medical doctors. Practitioners perform spinal manipulation by using their hands or a device to apply a controlled force to a joint of the spine. The amount of force applied depends on the form of manipulation used

Behavior Therapy

Started in the late 1960's Theory - Eating and exercise behaviors are learned and can be unlearned Need to alter environmental cues and reinforcers that control behavior

Eating Before Endurance

Subjects were told to: Bike moderately hard for as long as possible One group got 400 calories of CHO 3 hours before the test and biked for 136 minutes Another group got water 3 hours before the test and biked for 109 minutes [400 kcals of CHO=cereal, milk & banana] Exercising on an empty stomach can lead to decreased intensity and therefore decreased total calorie burn Exercising on an empty stomach can lead to increased use of muscle mass for fuel

Definition of Weight Loss Maintenance

Successful weight loss maintenance is defined as: Intentionally losing at least 10% of body weight AND Keeping it off at least one year.

Physical Warning Signs

Sudden or rapid weight loss Frequent changes in weight Sensitivity to the cold (feeling cold most of the time, even in warm environments) Loss or disturbance of menstrual periods (females) Signs of frequent vomiting - swollen cheeks / jawline, calluses on knuckles, or damage to teeth Fainting, dizziness Fatigue - always feeling tired, unable to perform normal activities

Tai chi and qi gong and yoga

Tai chi and qi gong are practices from traditional Chinese medicine that combine specific movements or postures, coordinated breathing, and mental focus The various styles of yoga used for health purposes typically combine physical postures or movement, breathing techniques, and meditation

Summarize

Teach patient to monitor thinking 2. Help patient see connection between dysfunctional thoughts and maladaptive behaviors 3. Examine evidence for validity of beliefs 4. Substitute more realistic interpretations based on evidence 5. Modify underlying assumptions that are determinants of dysfunctional beliefs

Changes

Term exchanges outdates so title changed to Choose Your Foods: Exchange Lists for Diabetes Starch+fat category eliminated from the Starch list A dairy-like products category (soy and rice milks) has been added to the Milk list Leafy vegetables moved from Nonstarchy Vegetable list to Free Foods list Very lean meats has been integrated into the Lean Meats list and a Plant-Based Protein list has been added Other Carbohydrates (Sweets, Desserts and Other Carbohydrates, Combination Foods, and Fast Foods) have been subdivided of ease of use Alcohol list has been added Sidebars with suggestions, design changes to make more user friendly, written for sixth grade reading level, area for personalized nutrition goals, ideas for determining exchanges from Nutrition Facts labels have been added Can still be used for diabetics, carbohydrate counting, and weight loss diets

Group Therapy

The main purpose of group therapy is to provide a supportive network of people who have similar issues to explore issues around their eating disorder. Groups may address many issues from alternative coping strategies, underlying issues, ways to change behaviors, triggers to personal needs and long-term goals. Groups are generally closed in attendance for a specific period of time (eg. 8 weeks).

Functional Foods

The term functional foods has no legal meaning in the United States. It is currently a marketing, rather than a regulatory, idiom. IFIC considers functional foods to include any food or food component that may have health benefits beyond basic nutrition IFT defines functional foods as foods and food components that provide a health benefit beyond basic nutrition (for the intended population). ADA places functional foods into categories given in the following table (See Position of the American Dietetic Association: Functional Foods, JADA 2009;109:735-46)

The Maintenance Problem

The weight loss people experience from a weight-loss treatment program is often not maintained over time

Mind-Body Practices

These focus on the interactions among the brain, mind, body, and behavior, with the intent to use the mind to affect physical functioning and promote health. Some techniques that were considered CAM in the past have become mainstream (for example, patient support groups and cognitive-behavioral therapy). Other mind-body techniques are still considered CAM include meditation, yoga, deep-breathing exercises, guided imagery, hypnotherapy, progressive relaxation, qi gong, and tai chi. Traditional Chinese medicine and Ayurveda consider the mind important in the treatment of disease Acupuncture is a technique in which practitioners stimulate specific points on the body—most often by inserting thin needles through the skin. Massage therapy includes many different techniques in which practitioners manually manipulate the soft tissues of the body. Most meditation techniques, such as mindfulness meditation or transcendental meditation, involve ways in which a person learns to focus attention. Movement therapies include a broad range of Eastern and Western movement-based approaches; examples include Feldenkrais method, Alexander technique, Pilates, Rolfing Structural Integration, and Trager psychophysical integration Relaxation techniques, such as breathing exercises, guided imagery, and progressive muscle relaxation, are designed to produce the body's natural relaxation response

Activity Guidelines

To promote and maintain health: 150 minutes/week of moderate intensity aerobic activity OR Vigorous intensity aerobic activity for 75 minutes/week Activity should be performed in at least 10 minute bouts, and be spread throughout the week PLUS Muscular strength and endurance 2 days/week Can accumulate activity in small amounts throughout the day (10 min. bouts)

Physical Effects BN

Tooth decay Dehydration Stomach & intestinal ulcers Inflammation & rupture of the esophagus Irregular or slow heart beat Heart failure Erosion of dental enamel from vomiting Swollen salivary glands The possibility of a ruptured stomach Chronic sore throat and gullet Sore throat, indigestion, heartburn and reflux Abdominal pain and bloating Electrolyte imbalance resulting in cardiac arrhythmia, muscle fatigue and cramps Bowel problems, constipation, diarrhea, cramps

Therapeutic Lifestyle Change Diet

Total fat-25-35% of total calories Saturated fat-<7% of total calories Trans-fatty acids-Zero or as low as possible Polyunsaturated fat-Up to 10% of total calories Monounsaturated fat-Up to 20% of total calories Carbohydrate-50-60% of total calories, especially from whole grains, fruits and vegetables Fiber-25-30 g/day(soluble forms) Plant sterols-2 g/day Protein-Approximately 15% of total calories Cholesterol-<200 mg/day Total calories-balance intake and expenditure

Sources of Fuel: Training

Training can increase capacity for fatty acid metabolism Ultimate goal is to increase the availability of fat as fuel during endurance exercise - do this through training. Training also increases body's ability to store glycogen for fuel.

Summary of Randomized Clinical Trials of Behavioral Therapy for Weight Loss

Treatments led to 10.7lb weight loss, about 11% of initial body weight = successful ... Summary of randomized clinical trials of behavior therapy for weight loss Behavior therapy can be provided in either group or individual sessions. Patients treated with a comprehensive group behavioral approach lose approximately 9% of initial weight in 20 to 26 weeks of treatment. This table summarizes the results from prospective randomized trials published in four behavioral journals from 1974 to 1999 [1]. Although the rate of weight loss induced by behavioral therapy has remained constant for the last 25 years, total weight loss has more than doubled because treatment duration has increased. Weight regain is common after cessation of therapy, with patients typically regaining about 35% of their lost weight within 1 year. Nonetheless, most patients still maintain a medically important weight loss of at least 5% of initial body weight at the end of 1 year. Continued behavior therapy does not lead to additional weight loss but is important for maintaining weight loss.

Problems with DRIs

Using EARs, individual requirements are almost never known Measuring usual intake is difficult due to day-to-day variation in intake Statistical approach called a Z scores is used to estimate the level of confidence that an individual's usual intake meets their requirement Using AIs make intake data even more difficult to interpret Group assessments are done using a probability approach or and EAR Cut-Point Method—mean intakes are not very helpful in reporting group data Individuals should pay particular attention to RDAs (or AIs) as a goal for average daily intake and ULs as an indicator of highest safe intake. EARs will be used by dietitians and others planning diets, developing new foods, and setting policies for food supplies for groups and populations.

Why Patients Use Complementary Therapies

Value whole person emphasis Orthodox treatment didn't work Adverse effects of orthodox medicine Active participation in treatment Poor doctor communication

Diet Calorie Levels

Very Low Calorie Diet (VLCD) - 400-800kcal Low Calorie Diet (LCD) - 800-1200kcal Balanced Deficit Diet (BDD) - >1200kcal Unbalanced Deficit Diet - Any kcal level, weird rules

Specific Examples

Vitamin D in infants, children and adolescents Folic acid in childbearing age women Folic acid during pregnancy, MVM and iron for some pregnancies Vitamin B-12 and D for older adults Vitamin D for dark skinned individuals

Replacing Fluid Loss

Water not sufficient.... Must replace sodium and potassium losses Drinking just water dilutes blood volume increases urine output decreases thirst mechanism

Recovering from Relapse

Weight Control Registry: Between Years 1 and 2.... Only 11% recovered from gains of 1-2 kg Magnitude of weight regain at yr 1 was the strongest predictor of outcome from year 0 to 2 i.e. the more weight you gained in year 1, the more weight you were likely to have gained by year 2 Need to catch weight gain early

Strategies for Long-Term Weight Management

Weight Loss Program Diet Pharmacotherapy Extended Care Social Support Exercise/Physical Activity Dietary patterns Self-regulation

Obesity Treatment

Weight Loss Reduces: Risk for Cardiovascular disease High blood pressure Diabetes Frequency of sleep apnea Surgical risk and complications Low back pain and osteoarthritis Weight Loss Improves: Mood Body image Self-esteem Interpersonal functioning Blood glucose control CVD indicators

Does Dieting Consistency Matter?

Weight Loss Registry: Dieters who maintained the same diet on weekdays and weekends were 1.5 times more likely to maintain their weight within 5 lbs. over the year Dieters who maintained their diet on holidays and vacations were 1.3 times more likely to maintain their weight within 5 lbs. over the year To be most successful, you can't take breaks from your diet

Weight Loss vs. Maintenance Dietary Behaviors

Weight Loss: Associated with Eating plenty of fruits or veggies Eating healthy snacks Limiting amount of carbs you eat Limiting amount of sugar consumed Weight Loss Maintenance: Associated with Eating plenty of fruits or veggies Limiting amount of carbs you eat Eating plenty of low-fat sources of protein

Weight Loss vs. Weight Maintenance - Exercise

Weight Loss:Do different kinds of exercises Do exercises that you enjoy Weight Maintenance Follow a consistent exercise routine

Physical Effects BED

Weight gain, often leading to obesity High blood pressure High cholesterol Chronic kidney problems or kidney failure Osteoarthritis Diabetes Stroke Complications during pregnancy Gallbladder disease Irregular menstrual cycle Skin disorders Heart disease Certain types of cancer

Allopathic medicine

Western Medicine

Considerations

When quantitative assessments of nutrient intake are conducted Need accurate dietary intake data Correct DRI needs to be selected Results need to interpreted appropriately

Whole Medical Systems

Whole medical systems are built upon complete systems of theory and practice. Often, these systems have evolved apart from and earlier than the conventional medical approach used in the United States. Examples of whole medical systems that have developed in Western cultures include homeopathic medicine and naturopathic medicine. Examples of systems that have developed in non-Western cultures include traditional Chinese medicine and Ayurveda.

Other Thoughts

Why do we have so much chronic disease? Is the combination of western medicine and drugs the answer to this dilemma? How do we determine individual nutrient needs? Are there incidences in people's lives due to stress or other unidentified causes that allow the breakdown of body systems and allow diseases to attack the body?

Nutrients from Foods

Wise selection of nutrient-dense foods is generally the best strategy for meeting nutrient needs. Foods, particularly plant foods such as fruits, vegetables, whole grains, beans, nuts, seeds, and teas, provide an array of other health-promoting substances beyond vitamins and minerals, including carotenoids and polyphenols such as flavonoids. Data suggest that positive health outcomes are related more to dietary patterns, the types and amounts of foods consumed than to intakes of individual nutrients.

Weight Loss With Friends

With friends: 95% completed treatment; 66% maintained weight loss Alone: 76% completed treatment; 24% maintained weight loss More people complete treatment and maintain weight loss when in program with friends

DSM-5Diagnostic and Statistical Manual of Mental Disorders

Written by the American Psychological Association which is a society of psychiatric physicians Used by assessment doctors (GPs and psychiatrists) to pass on information to individuals treating clients (psychologists or dietitians)

Adequate Intake (AI)-

a recommended intake value based on observed or experimentally determined approximations or estimates of nutrient intake by a group (or groups) of healthy people that are assumed to be adequate-used when an RDA cannot be determined

Integrative medicine

combines mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness

Dogs As Exercise Partners?

dog owners=300mins/week non=168mins/week

Recovery Electrolytes...potassium

potato-840mg yogurt-520mg oj-475mg banana-450mg raisins-300mg gatorade-30mg coke-5mg

Tolerable Upper Intake Level (UL)-

the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects for almost all individuals in the general population. As intake increases above the UL, the potential risk of adverse effects increases

Restricting type

this is the most commonly known type of Anorexia Nervosa whereby a person severely restricts their food intake. Restriction may take many forms (e.g. maintaining very low calorie count; restricting types of food eaten; eating only one meal a day) and may follow obsessive and rigid rules (e.g. only eating food of one color).

Muscle Glycogen per 100 grams of Muscle

untrained muscle: 18g trained muscle: 32g carbo-loaded muscle: 35-40g

Alternative medicine

used in place of conventional medicine

Complementary medicine

using techniques, practices and therapies from conventional (Western) and alternative medicine