Obesity Treatment: How to
make a difference with your
clients
Claudette Peck, LCMHC, RD, LD
Staff Nutritionist
Dartmouth College Health Service
Obesity Trends* Among U.S. Adults
BRFSS, 1991-2002
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)
1991
1995
2002
No Data
<10%
10%–14%
15%–19%
20%–24%
cdc.gov/nccdphp/dnpa/obesity/tre
nd
≥25%
2007 Obesity Map
What are we dealing with?
2/3 of Americans meet the criteria for
overweight (BMI>25)
 Risks: Combination of BMI and waist
circumference



Males >40 inches
Women>35 inches
Disease risks significantly increase with
combination of BMI>25,>30, >35, >40
Risk of Associated Disease According to BMI and Waist Size
Waist less than or
equal to
BMI
Waist greater than
40 in. (men) or
40 in. (men) or
35 in. (women)
35 in. (women)
18.5 or less
Underweight
--
N/A
18.5 - 24.9
Normal
--
N/A
25.0 - 29.9
Overweight
Increased
High
30.0 - 34.9
Obese
High
Very High
35.0 - 39.9
Obese
Very High
Very High
40 or greater
Extremely Obese
Extremely High
Extremely High
Assessment Factors







Weight/BMI
Waist Circumference: Men>40 inches,
Women>35 inches
Blood pressure: >130/85mm Hg
Fasting glucose: >110 mg/dL
Triglycerides: >150mg/dL
HDL: Men <40mg,dL; Women <50 mg/dL
Any 3 of the above = Metabolic Syndrome
Other risks: Cigarette smoking, Age, Gender,
Family History
Genes vs. Environment

“Genetics loads the
gun—the
environment pulls
the trigger.”
Influences on Food Intake







Social pressure to eat
Holidays & Special Events
Marketing/Advertisements
Time of Day
Paired eating activities
Emotions
Others…
Implications for improving
effectiveness of Interventions

Study by Ogden (2000) showed weight
loss maintainers(>3 years of
maintenance weight) when speaking of
reasons for weight loss motivation, less
endorsed medical reasons, more
endorsed psychological consequences
and indicated they had been motivated
to lose weight for psychological
reasons.
Anti-Fat Beliefs



Clear discrimination has been documented in 3 areas:
education, health care and employment.
The reason for this appears to be very strong anti-fat
attitudes.
For example, 28% of teachers in one study said that
becoming obese is the worst thing that can happen
to a person; 24% of nurses said they are 'repulsed'
by obese persons; and, controlling for income and
grades, parents provide less college support for their
overweight children than for their thin children.
Brownell, K., & Puhl, R. (2003). Stigma and Discrimination in Weight Management and Obesity,
The Permanente Journal, Summer 2003/7 (3)
Obesity Bias: What are your
beliefs?



Attitudes Toward Obese Persons scale
(ATOP)
Beliefs about Obese Persons scale
(BAOP)
Implicit Attitudes Test (IAT)
How do other providers feel
about the Obese?

Primary care physicians report that key
barriers to weight loss counseling are:





Self perceived low competence in treating
obesity
Lack of treatment effectiveness
Poor patient motivation
Time constraints
Lack of reimbursement
Befort, CA, et al (2006) Weight-Related perceptions among patients and
physicians. J. Gen Intern Med, 21 (1086-1090).
Additionally…

In a study of 620 primary care
physicians, 40% agreed that obese
patients could reach a normal weight if
they were motivated, but that most
patients would not be motivated
enough to lose a significant amount of
weight.
Befort, CA, et al (2006) Weight-Related perceptions among patients and physicians.
J.Gen Intern Med, 21(1086-1090).
Motivation
Motivational Interviewing (MI)



MI emphasizes the identification of
differences between a client’s current
behavior and his/her desired goals.
MI acknowledges ambivalence and
“resistance” as part of the process vs. a lack
of motivation.
MI requires the helper to be reflective vs.
directive.
DiLillo, V., Siegfried, N.J., & West, D.S. (2003). Incorporating motivational interviewing into
behavioral obesity treatment. Cognitive and Behavioral Practice, 10, 120-130.
Importance/Confidence Scale
How important is it for you right now to change your
behaviors?
On a scale of 0-10 what number would you give yourself?
0…………………………………………………….10
Not at all important
extremely important
What would need to happen for you to go from x to y?
Importance/Confidence Scale
If you decide to change, how confident are you that you could
do it?
On a scale of 0-10 what number would you give yourself?
0……………………………………………………10
Not at all confident
extremely confident
What would need to happen for you to go from
x to y?
Termination
Maintenance
Relapse
Action
Contemplation
Preparation
Precontemplation
Transtheoretical Stages of Change
Prochaska, Norcross & DiClemente
(1994)
Where to go from here…

If a client answers either question between 1-4,
assume they are in pre-contemplation and consider
the following steps:







Validate their experience
Acknowledge the client’s control of decision
Give your opinion on the medical benefits of weight loss
Explore concerns from the client’s view
Acknowledge possible feelings of being pressured to change
Validate that they are not ready and that it is solely their
decision
State that, at this time they are not ready, but that it is
possible they may feel differently at a future time.
www.cellinteractive.com/ucla/phys
cian_ed/interview_alg.html
Where to go from here (con’t)

Answers between 5-7 indicate some
continued ambivalence, assume clients
are in contemplation.




Validate client’s experience
Restate that the decision to change is still completely their
own
Clarify pros and cons of changing behavior
Leave opportunity for continued movement toward change.
www.cellinteractive.com/ucla/phys
cian_ed/interview_alg.html
Where to go from here (cont’d)

If answers are between 8-10, assume they
are ready to take action and help prepare
them for behavior change.





Praise decision to change behavior
Identify and assist in problem solving regarding
obstacles
Encourage small initial steps
Help identify social supports
Provide future follow-up appointments to assist
with adherence
www.cellinteractive.com/ucla/phys
cian_ed/interview_alg.html
Diets vs. Non-Diet Approach
Nutritional Analysis of Various Diets:
“The Truth about Carbs”
Total Calories:
Atkins'
Induction
1,152
Atkins'
Ongoing
1,627
Atkins'
Maintenance
1,990
Carbohydrate
Addict's
1,476
Sugar
Busters
1,521
Weight
Watchers
1,462
Dean
Ornish
1,273
Food Guide
Pyramid
1,972
RDA,DRVs
& DRIs
2,000-2,200
NUTRIENTS:
Moisture (H2O),g
Fat g, (%kcal)
Saturated Fat, g
Monounsat. Fat, g
Polyunsat. Fat, g
Cholesterol, (mg)
Protein g, (%kcal)
CHO g, (%kcal)
Dietary Fiber, (g)
Vitamin E (mg)
Vitamin A (RE)
Thiamin, (mg)
Riboflavin, (mg)
Niacin, (mg)
Vitamin B6, (mg)
Folate, (ug)
Vitamin B12, (mg)
Vitamin C, (mg)
Calcium, (mg)
Phosphorus, (mg)
Magnesium, (mg)
Iron, (mg)
Zinc, (mg)
Sodium, (mg)
Potassium, (mg)
682
75, (59%)
29
31
6
753
102 ,(35%)
13, (5%)
3
3
669
0.5
1.3
18
1.2
135
8
67
294
1096
126
10.4
15
2934
1734
736
105, (58%)
49
36
11
1115
134, (33%)
35, (8.6%)
8
7
2183
1.4
2.5
20
1.8
391
8
95
1701
1993
294
12.6
14
4046
2562
1132
114, (52%)
44
41
19
955
125, (25%)
95, (19%)
13
10
2231
0.7
2
25
2.2
282
4.3
226
889
1418
233
8.7
11.7
3604
3339
746
89, (54%)
35
31
15
853
84, (23%)
87, (24%)
8
7
3039
0.8
1.8
16.4
1.8
176
6.5
53
640
1150
173
8.2
11
3192
2479
1696
44, (26%)
11
20
9
128
89, (23%)
176, (46%)
25
7
948
2.4
1.7
32
2.6
377
3.4
109
712
1510
400
20
11
4012
3020
1200
42, (25%)
9
18
9
116
73, (20%)
207, (56%)
26
29
5638
3
3.6
37
4
636
11.6
207
1147
1432
325
28
23
2243
3773
1993
13, (9%)
2
3
5
4
48, (15%)
258, (81%)
38
7
2318
1.8
1.5
17
2.5
615
1
380
1053
1181
477
24
8
3358
4026
1879
54, (24%)
17
19
15
154
90, (18%)
292, (59%)
22
40
4140
3.8
4.3
51
5.5
1010
17
288
1749
1800
425
39
31
2757
4718
none
65, (30%)
20
20
20
300
75, (15%)
299,(57%)
20-35
15
700
1.1
1.1
14
1.3
400
2.4
75
1000
700
320
18
8
2400
3500
Source: INR (Institute for Natural Resources), 2004 "Weight Matters: Obesity, Hormones, & Appetite", Table 9, pp 9-10.
Note: Items in Bold indicate values different from recommendations
*RDA and DRIs used are those of a female, 31-50 years old.
Dietary Recommendations





Kcal restrictions-1200-1500/day to promote weight loss
Low carb-more weight loss in short-term; no difference
in losses long-term
Meal replacements-may be helpful in LCD, may help to
alter appetite expectations
Fat, Fiber, and Protein all shown to be helpful in
satiety. Protein especially important in maintaining
lean body tissue during weight loss
Nutrient distribution seems less important to overall
kcal reduction
The Bottom Line…

“Reduced-calorie diets result in clinically
meaningful weight loss regardless of
which macronutrient they emphasize.”
Sacks, F. M., Bray, G. A., Carey, V. J., et al.,(2009). Comparison of weightloss diets with different compositions of fat, protein, and
carbohydrates. NEJM, 360(9), 859-873.
Realistic and Reasonable
Goals for weight loss



8-10% reduction in weight in first 6
months
Most weight loss occurs in first 12
weeks of program
Secondary goal: To sustain momentum
and maintain weight loss
Discrepancies in Expectations
Patients’
beliefs
Expected
weight loss
goals
24-38% loss
of initial
weight
Physicians’
beliefs
Expected
weight loss
goals
14% loss of
initial weight
Clinical
guidelines
Expected
weight loss
goals
10% loss of
initial weight
Befort, CA, et al (2006) Weight-Related perceptions among patients and physicians.
J.Gen Intern Med, 21(1086-1090).
Improving Adherence

“Attendance at group sessions strongly predicted
weight loss…. Several recent trials have shown that
continued contact with participants after weight loss
is associated with less regain. These findings
together point to behavioral factors rather than
macronutrient metabolism as the main influences on
weight loss.”
Sacks, F. M., Bray, G. A., Carey, V. J., et al.,(2009). Comparison of weightloss diets with different compositions of fat, protein, and
carbohydrates. NEJM, 360(9), 859-873.
Fit vs. Fat: Can you be both?


Overweight and obese people who are fit are less
likely to die prematurely than unfit people who are
lean (Lee, CD, et al., Am J Clin Nutr 1999; 69:373-380)
Highly Fit men with 2 or 3 risk factors had about the
same mortality risk as Low Fit men with no risk (Blair,
SN, et al., JAMA 1996; 276: 205-210)

Low Fitness is as significant a risk factor for
premature death as smoking, high blood pressure,
diabetes, and high blood cholesterol, regardless of
weight ( Barlow et al., Int J Obes Metab Disord, 19(suppl 4):41, 1995 and
Wei et al., JAMA, 282: 1547, 1999)
Where does exercise fit into
weight loss planning?
Physical Activity (PA)




PA prevents weight gain
PA enhances weight loss
PA is the best predictor of weight loss
maintenance.***
Ultimate goal in behavioral
interventions is to promote long term
adherence
Determining Exercise Needs



Research shows that approximately 4.5 hours of
moderate intensity exercise (55-69% max HR) that
results in an energy expenditure of at least 2000
calories per week, in combination with a reduced
caloric intake, will produce desirable results.
Intermittent exercise (10-15 minutes sessions) that
accumulate to 30-40 minutes per day, seems to be
as effective as continuous sessions.
Start slowly…
American College of Sports Medicine
www.acsm.org
Lifestyle Activities

Short bout exercise (10 minute intervals
of moderate activity) practiced multiple
times per day; shown to have better
adherence in meeting exercise goals,
with similar level of fitness.
What works? Answers from:
National Weight Control Registry




How the weight loss was accomplished: 45% of registry participants
lost the weight on their own and the other 55% lost weight with the
help of some type of program.
98% of Registry participants report that they modified their food intake
in some way to lose weight.
94% increased their physical activity, with the most frequently reported
form of activity being walking.
There is variety in how NWCR members keep the weight off. Most
report continuing to maintain a low calorie, low fat diet and doing high
levels of activity.
 78% eat breakfast every day.
 75% weigh themselves at least once a week.
 62% watch less than 10 hours of TV per week.
 90% exercise, on average, about 1 hour per day
http://www.nwcr.ws/Research/default.htm
Behavioral Recommendations




Accountability: Food Monitoring,
Weight Monitoring
SMART goals (Specific, Measurable,
Appropriate, Reasonable, Timely)
Non-diet Approach
Support
Food Diary
Name: ___________________________________
Food or Drink
(Description/Amount)
Time
*Hunger
Level
Date: ____________________Today is: Su M Tu W Th F Sa
Where
?
With
Whom
Doing What
Feelings/Mood
*Fullnes
s
After
Eating
Physical
Activity
Hunger-Fullness Scale
0
1
2
3
4
5
6
STARVED H-U-N-G-E-R COMFORT/NEUTRAL
7
8
9
10
F-U-L-L-N-E-S-S STUFFED
B/
P
When diet and exercise aren’t
enough…
Hebals/Medications


Medication may be indicated in cases
where BMI>30, and diet, behavior and
exercise are already being used.
For medication to cause weight loss, it
must: Reduce energy consumption, OR
Increase energy expenditure, Or
Interfere with energy absorption
Herbal/Medication Options

No current herbal/supplement on the market appears to provide
safe and effective use for weight loss. Most herbals or “natural”
products are either nervous system stimulants (caffeine or other
derivatives), or bulking agents (fibers).
 Orlistat (Xenical) approved for long-term use (interferes with fat
absorption reducing about 30% of fat consumed) Alli (over-thecounter) lower-dose Orlistat
 Sibutramine (Meridia) approved for long-term use (reduces
energy consumption by suppressing the appetite) Peak
concentration 6-7 hours, suggest client take about 6-7 hours
prior to most vulnerable eating time. Should be cautious with
patients with HTN, in which monitoring should occur routinely.
Medication Costs/Benefits


Medication can pose a financial burden
to client
With use of Orlistat or Sibutramine,
studies are indicating an additional 510% reduction in total weight as
compared to diet alone.
What are the surgical options?




Restrictive procedures have more
flexible criteria as they are both
adjustable and reversible.
Bypass surgery criteria are…
BMI>40
OR BMI>35 with comorbidities
Surgical Options
Options: Restrictive—Vertical Banded Gastroplasty
(VBG) and Lap Band (no malabsorption for either of
these) Restricts gastric volume
 Restrictive and Malabsorptive—Roux-en Y Gastric
Bypass and Distal Roux-en Y Gastric Bypass (restricts
gastric volume AND bypasses the duodenum and part
of jejunum, causing decrease in absorption of
calories)
Possible OutcomesRestrictive procedures show 15-20% loss of actual
weight, Bypass procedures show 25-30% loss of
actual weight. Most losses occur within first 6
months post-surgically.

Things that can make the
difference…




Provide a receptive environment including gowns,
tables, chairs, scales and cuffs that will fit this
clientele
Improving adherence by nurturing the client’s
motivation, assisting in developing specific behavioral
changes. Develop a relationship with your client.
Understanding ambivalence and resistance when
working with your client vs. judging their motives.
Be Aware of biases and attitudes

In a study done by Maiman et al., J Amer Diet Assoc., 1979… 87% of dietitians viewed
the obese as “self-indulgent”, 74% attributed “family problems to the obese, and 32%
indicated that obese patients “lack willpower”.
Case Study #1





43 y.o. female, single-mother of 3 children (ages 15, 13, 8),
works full-time. Ht 5’4”, weight 186 lbs. Family hx of DM type
II, HTN. Pre-pregnancy weight was 135 lbs, gained weight with
each pregnancy, but unsuccessful in taking it off. Complains of
fatigue and feeling stressed with work, home and
responsibilities. States, “I know that losing weight will help me
have more energy and feel better about myself, but the idea of
making changes seems overwhelming at this point.”
Where do you believe she is in terms of stage of change?
What else do you need to know?
What questions will you ask?
Describe the conversation you may/may not have with her?
Comments/Questions?
Kcals
Food Intake Patterns
1400
1600
1800
2000
2200
2400
2600
2800
Fruit
1.5 c
1.5 c
1.5 c
2c
2c
2c
2c
2.5 c
Veg
1.5 c
2c
2.5 c
2.5 c
3c
3c
3.5 c
3.5 c
Grain
5 oz
5 oz
6 oz
6 oz
7 oz
8 oz
9 oz
10 oz
Meat/B 4 oz
eans
5 oz
5 oz
5.5 oz
6 oz
6.5 oz
6.5 oz
7 oz
Milk
2c
3c
3c
3c
3c
3c
3c
3c
Oils
4 tsp
5 tsp
5 tsp
6 tsp
6 tsp
7 tsp
8 tsp
8 tsp
Extra*
kcals
171
182
195
267
290
362
410
426
Serving Sizes
1 cup of cereal = a fist
1/2 cup of cooked rice, pasta, or potato = 1/2 baseball
1 baked potato = a fist
1 medium fruit = a baseball
1/2 cup of fresh fruit = 1/2 baseball
1 1/2 ounces of low-fat or fat-free cheese = 4 stacked dice
1/2 cup of ice cream = 1/2 baseball
2 tablespoons of peanut butter = a ping-pong ball
Everyday
Objects
References and Websites







National Institutes of Health Publication No
02-4084. The Practical Guide: Identification,
Evaluation, and Treatment of overweight and
obesity in adults
http://win.niddk.nih.gov/index.htm
www.obesity.org
www.eatright.org
www.consumer.gov/weightloss
www.naaso.org
www.shapeup.org
Resources











www.mypyramid.gov
National Institutes of Health Publication No 02-4084. The
Practical Guide: Identification, Evaluation, and Treatment of
overweight and obesity in adults
http://win.niddk.nih.gov/index.htm
www.obesity.org
www.eatright.org
www.consumer.gov/weightloss
www.naaso.org
www.shapeup.org.
www.nwcr.ws/Research/default.htm
www.acsm.org
www.thelifestylecompany.com/
References
















Barlow, et al (1995). Int. J. of Obesity & Related Metabolic disorders, 19 (supplement 4),
41.
Befort, C.A. et al (2006). J. General Internal Medicine, 21 (1086-1090).
Blair, S. N., et al (1996). JAMA, 276, 205-210.
Brownell, K. & Puhl, R. (2003). The Permanente Journal, Summer (2003), 7,(3).
cdc.gov/nccdphp/dnpa/obesity/trend
DiLillo, V., Siegfried, N.J., & West, D.S. (2003). Incorporating motivational interviewing into
behavioral obesity treatment. Cognitive and Behavioral Practice, 10, 120-130.
http://www.health.gov/dietaryguidelines/dga2005/document/default.htm
Institute for Natural Resources. (2004). Weight Matters: Obesity, hormones & appetite.
Table 9, pp 9-10.
Lee, C. D., et al (1999). Am J Clin Nutr, 69, 373-380.
Ogden, J. (2000). Int. J of Obesity & Related Metabolic disorders, 24 (8), 1018-1025.
Prochaska, J. O., Norcross, J. C., & DiClemente, C. C. (1994). Changing for Good. New
York,: Avon Books.
Sacks, F.M., Bray, G.A., Carey, V. J. (2009). Comparison of weight-loss diets with different
compositions of fat, protein, and carbohydrate. NEJM, 360(9). 859-873.
www.nwcr.ws
www.acsm.org
www.aicr.org/press/NANAReport. (June 2000) From Wallet to Waistline: The hidden costs
of super sizing. The National Alliance for Nutrition and Activity (NANA).
www.cellinteractive.com/ucla/physcian_ed/interview_alg.html