‫سمینار تغذیه و چاقی‪ ،‬بیمارستان امام رضا (ع) کرمانشاه ‪94/8/28‬‬
‫‪1‬‬
‫‪Obesity Management conference.‬‬
‫‪Kermanshah‬‬
‫‪22،03،16‬‬
‫مقدمه‬
‫و‬
22،03،16
Obesity and Lifestyle Modification
2
‫چاقی‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪3‬‬
‫پژوهشگران می گویند هزینه ای که چاقی در سطح دنیا بر‬
‫دوش مردم و دولتها می گذارد به اندازه هزینه سیگار‬
‫کشیدن و درگیریهای مسلحانه است‬
‫مطالعات اپیدمیولوژیک نشان می دهند که روند چاقی در‬
‫دنیا در سالهای اخیر سرعت بسیار زیادی به خود گرفته و‬
‫در ‪ 34‬سال گذشته از سال ‪ 1980‬تا ‪ 2014‬دو برابر شده‬
‫است‪.‬‬
‫مساله اضافه وزن در ایران کمکم حالت فراگیر بهخودش‬
‫گرفته و در این بین آماری که وجود دارد‪ ،‬زنگ هشدار را‬
‫به صدا درآورده است‪.‬‬
‫‪Obesity Management conference.‬‬
‫‪Kermanshah‬‬
‫‪22،03،16‬‬
‫چاقی‬
‫‪‬‬
‫‪4‬‬
‫سازمان بهداشت جهانی چاقی را یکی از مهمترین بیماری‬
‫های غیر واگیر در حال گسترش تعریف کرده است که‬
‫ساالنه حدود ‪ 10‬تا ‪ 20‬درصد هزینه های بهداشتی یک‬
‫کشور را بطور مستقیم و غیر مستقیم درگیر می کند‪.‬‬
‫‪Obesity Management conference.‬‬
‫‪Kermanshah‬‬
‫‪22،03،16‬‬
‫چاقی‬
‫‪‬‬
‫‪‬‬
‫‪5‬‬
‫صرفنظر از نوع نگاه ما به چاقی بعنوان یک بیماری یا تنها‬
‫بعنوان یک عامل خطر‪ ،‬افراد مبتال به اضافه وزن و چاقی با طیف‬
‫وسیعی از بیماریها و عوارض حاصله روبرو هستند که نیازمند‬
‫اقدامات تشخیصی و درمانی دقیق و مبتنی بر شواهد علمی خواهند‬
‫بود‬
‫تاثیر چاقی بر فعالیت های اجتماعی و شغلی و بطور کلی کیفیت‬
‫زندگی نیز به نوبه خود بار اقتصادی – اجتماعی آن را می افزاید‬
‫‪Obesity Management conference.‬‬
‫‪Kermanshah‬‬
‫‪22،03،16‬‬
‫چاقی‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪6‬‬
‫امروزه چاقی بعنوان یک معضل اصلی نظام سالمت به موازات‬
‫دیابت قندی اپیدمی دو قلوی قرن بیست و یکم نام گرفته اند‬
‫‪ 65‬درصد جمعیت جهان در کشورهایی زندگی می کنند که افزایش‬
‫وزن و چاقی بیش از کم وزنی باعث مرگ و میر می گردند‬
‫ساالنه حدود ‪ 2.8‬میلیون نفر از افراد بالغ دنیا بعلت چاقی دچار‬
‫مرگ و میر می شوند‬
‫‪Obesity Management conference.‬‬
‫‪Kermanshah‬‬
‫‪22،03،16‬‬
‫چاقی‬
‫‪‬‬
‫‪‬‬
‫‪7‬‬
‫افزایش شیوع اضافه وزن و چاقی عالوه بر کشورهای‬
‫صنعتی بسیاری از کشورهای با در آمد پائین و متوسط‬
‫جهان را نیز با بار دوگانه بیماریها روبرو نموده است‬
‫در حالیکه این کشورها هنوز گرفتار مشکالت بیماریهای‬
‫عفونی و سوء تغذیه می باشند شیوع عوامل خطر‬
‫بیماریهای غیر واگیر از جمله اضافه وزن و چاقی‬
‫بخصوص در جمعیت شهر نشین این کشورها رو به تزاید‬
‫است‪.‬‬
‫‪Obesity Management conference.‬‬
‫‪Kermanshah‬‬
‫‪22،03،16‬‬
‫چاقی‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪8‬‬
‫افزایش روند چاقی در کودکان و نو جوانان نیز از نگرانی های‬
‫ویژه سالمت جامعه محسوب می گردد‬
‫شیوع اضافه وزن وچاقی در جمعیت باالی ‪ 20‬سال ایران ‪ 50‬تا‬
‫‪ 70‬درصد بوده ودر شهر تهران ‪ 50‬درصد افراد اضافه وزن‬
‫داشته و ‪ 15‬تا ‪ 20‬درصد در مرز چاقی قرار می گیرند‬
‫چاقی نتیجه یک واکنش پیچیده بین استعداد ژنتیکی‘ محیط زیست‬
‫و عوامل رفتاری در یک فرد است‪.‬‬
‫مصرف غذا های پر کالری و زندگی کم تحرک مهمترین عامل‬
‫اپیدمی چاقی در دنیا است‪.‬‬
‫با این وجود بروز و استمرار چاقی چند علیتی بوده و مداخالت‬
‫برای پیشگیری و درمان آن امیدوار کننده نیستند‬
‫‪Obesity Management conference.‬‬
‫‪Kermanshah‬‬
‫‪22،03،16‬‬
‫چاقی‬
‫‪‬‬
‫‪9‬‬
‫انجام پژوهش های بنیادی‪ ،‬اپیدمیولوژیکی و بالینی جهت‬
‫پی بردن به عوامل زمینه ساز بروز و استمرار چاقی و‬
‫شناخت هر چه بیشتر بیمایزایی و مداخالت درمانی مرتبط‬
‫با چاقی و ارائه راهکارهای مبتنی برشواهد بومی به‬
‫مسئولین ارائه دهنده خدمات بهداشتی‪-‬درمانی کشور به‬
‫منظور جوابگویی به نیازهای جامعه‪ ،‬اصالح رفتارها و‬
‫فراهم نمودن زمینه های سبک سالم زندگی بخصوص در‬
‫کودکان و نو جوانان تاثیرات قابل توجهی در پیشگیری از‬
‫بروز چاقی و روند رو به افزایش آن در کشور فراهم می‬
‫سازد‬
‫‪Obesity Management conference.‬‬
‫‪Kermanshah‬‬
‫‪22،03،16‬‬
‫چاقی‬
‫‪‬‬
‫‪10‬‬
‫چنین کنگره ها وسمینارهایی در خصوص پیشگیری و‬
‫درمان چاقی فرصت مناسبی است تا پژوهشگران جوان‪،‬‬
‫اندیشمندان و اساتید دانشگاه های علوم پزشکی کشور با‬
‫ارائه نتایج پژوهش های خود در حیطه چاقی‪ ،‬بحث‪ ،‬تبادل‬
‫نظر و هم اندیشی به راهکار های عملی و سودمندی برای‬
‫مبارزه با این معضل سالمت جامعه دست یافته و نظام‬
‫ارائه خدمات بهداشتی‪-‬درمانی کشور را در این زمینه‬
‫یاری رسانند‬
‫‪Obesity Management conference.‬‬
‫‪Kermanshah‬‬
‫‪22،03،16‬‬
‫چاقی‬
‫‪‬‬
‫‪11‬‬
‫به عقیده پژوهشگران‪ ،‬اقداماتی جزئی و اندک مفید نیستند‬
‫و به سلسله اقداماتی نظام مند نیاز است ومقابله با چاقی‬
‫باید در ابعاد ملی و در سطح دولتها مد نظر قرار گیرد و‬
‫راه حل معجزه آسایی برای آن وجود ندارد‬
‫‪Obesity Management conference.‬‬
‫‪Kermanshah‬‬
‫‪22،03،16‬‬
‫چاقی‬
‫مطالعات و شواهد زیادی نشان مئ دهند‬
‫که هنوز دولت های جهان به اهمیت و‬
‫عوارض چاقی توجه کافی نمی کنند!‬
‫‪12‬‬
‫‪Obesity Management conference.‬‬
‫‪Kermanshah‬‬
‫‪22،03،16‬‬
‫چاقی‬
‫روند افزایشی چاقی در بین افراد بالغ و کودکان ایرانی نیز‬
‫همچون دیگر کشورهای دنیاست که باید برای مقابله با آن‬
‫برنامه ریزی های الزم پیشگیرانه اعمال شود که جلوگیری‬
‫از پرخوری و فرهنگسازی در راستای تحرک بدنی و‬
‫ورزش به ویژه در بین جوانان و نوجوانان از جمله این‬
‫موارد به شمار می رود‬
‫‪13‬‬
‫‪Obesity Management conference.‬‬
‫‪Kermanshah‬‬
‫‪22،03،16‬‬
‫چاقی‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪14‬‬
‫چاقي یك بیماري مزمن است و مثل هر بیماري مزمن‬
‫دیگري درمان آن نیاز به زمان دارد‬
‫در درمان چاقي‪ ،‬هیچگاه عجله نداشته باشید‪ ،‬یادتان باشد‬
‫كه رژیم غذایي با كاهش وزن تدریجي عالوه بر اینكه قابل‬
‫تحملتر است‪ ،‬عوارضي نداشته‪ ،‬تقریبا غیر قابل بازگشت‬
‫ميباشد‬
‫چاقي با بسیاري از بیماریها چه مستقیم و چه غیرمستقیم‬
‫ارتباط دارد‬
‫چاقي باعث كاهش عمر ميشود‬
‫‪Obesity Management conference.‬‬
‫‪Kermanshah‬‬
‫‪22،03،16‬‬
PEN
Package of Essential
Noncommunicable (PEN) Disease
Interventions for Primary Health Care
in Low-Resource Settings
WHO 2010-2025
22،03،16
Obesity Management conference.
Kermanshah
15
IMPLEMENTATION TOOLS
PEN
CANCER
HEART DISEASE AND STROKE
DIABETES
CHRONIC RESPIRATORY DISEASE
22،03،16
Obesity Management conference.
Kermanshah
16
Global Monitoring Framework
9 targets for 2025
Physical inactivity
10% reduction
Treatment to reduce risk
of heart attacks
and strokes
50% coverage
Diabetes /Obesity
0% increase
Harmful use of alcohol
10% reduction
Premature mortality
From NCD
25% reduction
Raised BP
25% reduction
Salt/sodium
Intake
30% reduction
Essential medicines
& technologies
Tobacco use
30% reduction
22،03،16
Obesity Management conference.
Kermanshah
80% coverage
17
‫سند ملی پیشگیری و کنترل بیماریهای غیر‬
‫واگیر وعوامل خطر در ایران در بازه زمانی‬
‫‪ 1394‬تا‪1404‬‬
‫کمیته و دبیرخانه ملی پیشگیری از بیماریای غیرواگیر‬
‫اعضاء‪:‬‬
‫وزیر بهداشت‬
‫معاونین‬
‫و‪.....‬‬
‫‪18‬‬
‫‪Obesity Management conference.‬‬
‫‪Kermanshah‬‬
‫‪22،03،16‬‬
‫سند ملی پیشگیری و کنترل بیماریهای غیر واگیر‬
‫وعوامل خطر در ایران در بازه زمانی ‪ 1394‬تا‪1404‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪19‬‬
‫اعضای شورای عالی سالمت‬
‫معاون اول رییس جمهور‬
‫سخنگوی دولت‬
‫رییس سازمان محیط زیست‬
‫وزیر راه و شهرسازی‬
‫وزیر فرهنگ‬
‫وزیر نیرو‬
‫وزیر حهاد کشاورزی‬
‫رییس سازمان صدا و سیما‬
‫وزرای آموزش و پرورش‪ ،‬کشور‪ ،‬اقتصاد‪ ،‬صنعت‪ ،‬ورزش و جوانان ‪،‬تعاون کار و بهداشت‬
‫‪Obesity Management conference.‬‬
‫‪Kermanshah‬‬
‫‪22،03،16‬‬
‫اهداف و تعهدات جمهوری اسالمی در قالب سند ملی‬
‫‪ ‬کاهش ‪ %20‬از میزان تحرک بدنی ناکافی‬
‫‪ ‬کاهش ‪ %10‬از مصرف الکل‬
‫‪ ‬کاهش ‪ %30‬از مصرف نمک سدیم‬
‫‪ ‬کاهش ‪ %30‬از شیوع دخانیات‬
‫‪ ‬کاهش ‪ %25‬از شیوع پرفشاری خون‬
‫‪ ‬جلوگیری از افزایش چاقی و دیابت جمعیت‬
‫‪20‬‬
‫‪Obesity Management conference.‬‬
‫‪Kermanshah‬‬
‫‪22،03،16‬‬
‫اهداف و تعهدات جمهوری اسالمی در‬
‫قالب سند ملی‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪21‬‬
‫دسترسی ‪ %100‬جمعیت به داروهای مناسب و فن آوری‬
‫پایه و ضروری برای درمان بیماریهای غیر واگیر‬
‫کاهش ‪ %25‬از خطر مرگهای زودرس ناشی از‬
‫بیماریهای غیر واگیر‬
‫دسترسی حداقل ‪ %70‬مردم به دارو و مشاوره الزم برای‬
‫پیشگیری از بیماریهای قلبی و عروقی و حمالت عروق‬
‫مغزی‬
‫میزان صفر اسیدهای چرب ترانس در روغنهای خوراکی و‬
‫محصوالت غذایی‬
‫‪Obesity Management conference.‬‬
‫‪Kermanshah‬‬
‫‪22،03،16‬‬
‫بیماری های‬
‫تنفس ی مزمن‬
‫اختالالت روانی‬
‫آسیب ها‬
‫نداشتن فعالیت فیزیکی‬
‫سرطان‬
‫دیابت‬
‫بیماری های‬
‫قلبي و عروقي‬
‫رژیم غذایی ناسالم‬
‫مصرف الکل‬
‫‪22‬‬
‫شرایط و بیماری های‬
‫غیر واگیر‬
‫‪Obesity Management conference.‬‬
‫‪Kermanshah‬‬
‫عوامل خطر‬
‫‪22،03،16‬‬
‫ شهرستان‬4
‫ بافت‬
‫ شهرضا‬
‫ نقده‬
‫ مراغه‬
22،03،16
Obesity Management conference.
Kermanshah
23
‫برنامه ملی اصالح سبک زندگی‬
22،03،16
Obesity Management conference.
Kermanshah
24
‫برنامه ملی فعالیت بدنی برای ارتقای سالمت‬
‫در ایران‬
National Physical Activity
Plan
for Health Promotion in IR Iran
22،03،16
Obesity Management conference.
Kermanshah
25
Physical Inactivity in Iran
1390
1388
1387
1386
1385
Gender Age
48.77
49.91 49.88
46.36
40.34
Women 15-64
31.53
28.28 26.60
24.32
21.60
Men
40.09
38.97 38.10
35.21
30.85
All
22،03،16
Obesity Management conference.
Kermanshah
26
‫برنامه ملی فعالیت بدنی برای ارتقای‬
‫سالمت در ایران‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪27‬‬
‫فعالیت بدنی در کودکان ‪0‬تا ‪ 4‬ساله‬
‫فعالیت بدنی در کودکان ‪5‬تا ‪ 11‬ساله‬
‫فعالیت بدنی درسنین ‪ 12‬تا ‪ 17‬ساله‬
‫فعالیت بدنی درسنین ‪ 18‬تا ‪ 64‬ساله‬
‫فعالیت بدنی درسالمندان ‪ 65‬ساله و باالتر‬
‫‪Obesity Management conference.‬‬
‫‪Kermanshah‬‬
‫‪22،03،16‬‬
22،03،16
Obesity and Lifestyle Modification
28
Obesity Is Caused by Long-Term Positive Energy Balance
Fat
Stores
22،03،16
Obesity and Lifestyle Modification
29
Body Mass Index (BMI) is the
global method of determining
overweight/obesity
BMI = wt/ht²
(kg/m²)
(lbs/in²)x704.5
At a similar BMI, women have more body fat than men
22،03،16
Obesity and Lifestyle Modification
30
Definitions
 Normal:
BMI 18.5 - 24.9
 Overweight:
25 -29.9
 Obese:
>= 30
Class I
30 - 34.9
Class II
35 - 39.9
Class III
>= 40
22،03،16
Obesity and Lifestyle Modification
31
OBESITY

According to the WHO, more than two billion people will
be overweight by next year and as many as 700 million of
them obese
Behavioral Disinhibition Can Foster Intentions to Healthy Lifestyle
Change by Overcoming Commitment to Past Behavior
Bob M. Fennis et al November 11, 2015
DOI: 10.1371/journal.pone.0142489
22،03،16
Obesity and Lifestyle Modification
32
Obesity & Mortality
- Large epidemiologic studies have evaluated the
relationship between obesity and mortality
- Greater body mass index (BMI) is associated with
increased rate of death from all causes
- ↑ BMI (each 5 kg/m2 ( → 30 % ↑ in overall mortality
- Only being overweight (BMI ≥ 25) also → ↓ survival
22،03،16
Obesity and Lifestyle Modification
33
The scope of overweight/obesity

52% of US adults are overweight or obese!


ONE HALF!
Prevalence is INCREASING!
30% increase in adults in two decades
 >80% increase in children/adolescents!!!


Second-leading PREVENTABLE cause of
death in the US
22،03،16
Obesity and Lifestyle Modification
34
Factors contribute to the development of
obesity










Sedentary lifestyle
Lack of information
Ill- heath and physical disability
Psychological factors such as overeating
Social pressures
Genetic make – up
Endocrine disorder
Certain drug treatment
Socioeconomic status
Weight gain in childhood
22،03،16
Obesity and Lifestyle Modification
35
Obesity is associated with increased risk of
co-morbid conditions:





Hypertension
Dyslipidemia
Diabetes mellitus
Coronary artery dz.
Cerebrovascular dz.





Gallbladder dz.
Sleep apnea
Osteoarthritis
Gout
Cancers


OVERALL
MORTALITY
HIGHER!




22،03،16
Colon
Breast
Prostate
Uterus
Cervix
Obesity and Lifestyle Modification
36
Obesity Therapy
Energy
Intake
Energy
Expenditure
Adipose
tissue
22،03،16
Obesity and Lifestyle Modification
37
AIMS OF TREATMENT OF
OBESITY



Reduction of weight to within the desirable range
Education of the obese individual into a new
lifestyle which ensures that the body – weight is
maintained at the new level
Maintenance of an adequate intake of all nutrients.
22،03،16
Obesity and Lifestyle Modification
38
TREATMENT OF OBESITY





Those categories of individuals who should be
given priority in advice on how to lose weight
should include:
BMI >30
BMI > 25 who also have other cardiovascular risk
factors
Those with medical condition that are exacerbated
by obesity
Those who have an abdominal distribution of fat
22،03،16
Obesity and Lifestyle Modification
39
Obesity Treatment Pyramid
Surgery
Pharmacotherapy
Lifestyle Modification
Diet
22،03،16
Physical Activity
Obesity and Lifestyle Modification
40
LIFESTYLE?
The term lifestyle can denote the interests,
opinions, behaviors, and behavioral
orientations of an individual, group, or
culture
 The way a person lives
Lifestyle from Merriam-Webster's Dictionary

22،03،16
Obesity and Lifestyle Modification
41
HEALTHY LIFESTYLE?






Healthy weight
Healthy diet
Physically active
Stress and anxiety management
No smoking
Alcohol consumption
22،03،16
Obesity and Lifestyle Modification
42
UNHEALTHY LIFESTYLE

Unhealthy lifestyle characteristics:


Physical inactivity
Excess body mass
Poor diet
Smoking and ….

Associated poor health metrics:

Dyslipidemia
Hyperglycemia
Hypertension and …




Who will deliver comprehensive healthy lifestyle interventions to combat non-communicable
disease? Introducing the healthy lifestyle practitioner discipline.
Arena R1, Lavie CJ, Hivert MF, Williams MA, Briggs PD Guazzi M
22،03،16
Obesity and Lifestyle Modification
43
EXERCISE AND WEIGHT
REDUCTION



420 KJ (100kcal) is expended for walking 1
mile
However , if incorporated it into a daily
routine , this can become of value
1 mile (1609.34 m) walked every day expends
the amount of energy stored in 3 kg adipose
tissue over 1 year
22،03،16
Obesity and Lifestyle Modification
44
PHYSICAL ACTIVITY (PA)
DEFINITION




PA is defined as any bodily movement created by
skeletal muscles that results in energy expenditure
PA includes sports, exercise and other activities
such as playing, walking, doing household chores
or gardening
This broad term means that PA includes almost
everything that a person performs
physical inactivity is, in contrast, the time spent to
do things that do not markedly increase energy
expenditure
22،03،16
Obesity and Lifestyle Modification
45
Exercise is also beneficial for
following reasons



Most individuals experience an improved
feeling of wellbeing during and after
Exercise
Resting metabolic rate is increased for a
period after Exercise
It is difficult to eat and exercise at the same
time
22،03،16
Obesity and Lifestyle Modification
46
PHYSICAL ACTIVITY



Physical inactivity is regarded a major public
health concern
Regular physical activity (PA) has been considered
as an important lifestyle modification to improve
health and prevent chronic disease
Setting the goal at walking 10,000 steps/day as a
moderate-intensity form of aerobic PA has been
advised to have beneficial health effects in the
research and practice areas.
22،03،16
Obesity and Lifestyle Modification
47
PHYSICAL INACTIVITY


Physical inactivity or sedentarism is
regarded as a major public health concern.
As a risk factor for chronic diseases, such as
obesity,
hypertension,
cardiovascular
disease, type 2 diabetes, osteoporosis,
several types of cancers, depression, and
anxiety, physical inactivity is responsible for
more than 2 million deaths annually around
the world
22،03،16
Obesity and Lifestyle Modification
48
PA RECOMMENDATION


)
PA recommendations
Walking as a PA recommendation
22،03،16
Obesity and Lifestyle Modification
49
The Activity Pyramid
Lifestyle activity is at
the base of the
pyramid because it is
something that
everyone can do on a
regular basis.
22،03،16
Obesity and Lifestyle Modification
50
ASUKI STEP STUDY




10,000 Steps per day
Reducing weigh, WC, SAD, and %Fat
Increasing VO2max
Decreasing Sys. And Dia. BP
22،03،16
Obesity and Lifestyle Modification
51
PA ASSESSMENT METHODS

Subjective techniques:
Self reported questionnaires (IPAQ)
Interviewer administered questionnaires
Mail surveys
Diaries

Objective techniques:

Pedometers
Accelerometers
heart rate monitors
Reference techniques:
Doubly labeled water
Indirect calorimetry









22،03،16
Obesity and Lifestyle Modification
52
ASSESSMENT OF PA



The amount of daily Physical activity is very
difficult to quantify
Typically an increase in weight of 10 kg occurs
over a period of perhaps 2 years. This indicates
that the individual has a positive energy balance of
same 30 – 40 kcal/day
This corresponds to an extra energy intake of less
than half a sandwich per day or , on the output side
, a walk of 15 -30 min / day
22،03،16
Obesity and Lifestyle Modification
53
PA AND DIET



A decrease in daily food intake of 1000 kcal is easily
managed , but this corresponds to about 3h of
jogging, an activity which is impossible for most
obese patient
Physical exercise appears to improve insulin
sensitivity without necessary creating a negative
energy balance.
This is seen as an acute effect after a bout of
exercise and lasts for a day or two
22،03،16
Obesity and Lifestyle Modification
54
THE IMPACTS OF PA





Improved blood
pressure
Increased HDL
Decreased serum
triglycerides
Increased caloric
expenditure
Decreased weight
22،03،16
Obesity and Lifestyle Modification
55
WEIGHT REDUCTION USING A
MULTIDISCIPLINARY APPROACH


Exercise without diet intervention seems to
cause only minor weight loss usually no
more than 1-2 kg
Weight
reduction
program
use
a
multidisciplinary approach. These include
dietary energy intake , Exercise , and
cognitive and behavioral therapy to promote
permanent lifestyle changes
22،03،16
Obesity and Lifestyle Modification
56
EXERCISE AND MAINTENANCE OF
AFTER WEIGHT LOSSS


If counseling is to be effective in increasing
an individuals Physical activity great
attention must be paid to his or her
motivation
Exercise prescribed by a therapist is unlikely
to be continued for the rest of lifetime
22،03،16
Obesity and Lifestyle Modification
57
Adopting an Active Lifestyle
Lifestyle activities are the foundation of
an active lifestyle
 Lifestyle activities include activities of
daily living and less intense sports and
recreational activities
 Should
expend more energy than
normally expended at rest

22،03،16
Obesity and Lifestyle Modification
58
Examples of Lifestyle Activities








Washing a car
Washing windows or floors
Gardening
Wheeling self in wheelchair
Park farther away in parking lot
Social dancing
Walk/bike to the store
Pushing a stroller
Walk breaks at work
Take stairs instead of elevators
Raking leaves
Add in Yard work
Walking
Count Housework as “activity”
22،03،16
Obesity and Lifestyle Modification
59
Advantages of Lifestyle Activity
Lifestyle activities can be
integrated into your daily routine
 Relatively easy to perform,
therefore they are popular among
adults
 Promotes metabolic fitness

22،03،16
Obesity and Lifestyle Modification
60
Occupational Physical Activity

In a famous study, bus
conductors who regularly
climbed stairs to collect
tickets from passengers
had lower rates of dying
than the more sedentary
bus drivers after
controlling for other risk
factors.
Walking up and down the stairs made a
significant difference in health risks.
22،03،16
Obesity and Lifestyle Modification
61
Try Taking the Stairs!

A great way to increase daily energy
expenditure is by taking the stairs instead of
the elevator (or just going up and down the stairs
several times during the day for quick breaks).


The estimated energy expenditure required
to go up and down 1 staircase (15 stairs) is
~ .022 kcal/lb (.0015kcal/lb/stair)
Example calculation:

Going up and down 4 flights of stair: 120 stairs


22،03،16
150 lb person: .0015 kcal/lb/stair x 150 lb x 120 stairs = 27 kcal
200 lb person: .0015 kcal/lb/stair x 200 lb x 120 stairs = 36 kcal
Obesity and Lifestyle Modification
62
:
What is a MET?



1 MET = resting energy expenditure
1 MET = 3.5 ml O2 / kg / min
1 MET = 1 kcal / kg / hour
1 MET = 1 Kcal/kg.h = 4.184 kj/kg.h
22،03،16
Obesity and Lifestyle Modification
63
Range of Intensities for
Lifestyle Physical Activity
Activity Level
Rest
Very Light
Light
Moderate
Hard
Very Hard
Maximum
22،03،16
MET Level
1
2 - 2.5
2.5 – 4. 2/3
4. 2/3 - 7
7 - 10
10 - 12
12+
Example
Resting
Typing
Normal Walk
Brisk Walk
Run 5 mph
Run 8.5 mph
Run 10 mph
Obesity and Lifestyle Modification
64
22،03،16
VERY HARD
HARD
MODERATE
LIGHT
VERY LIGHT
REST
1 2 3 4 5 6 7 8 9 10 11 12 +
MAXIMUM
Intensity of Exercise
Aerobic
Anaerobic
Exercise Continuum
METS
Obesity and Lifestyle Modification
65
Sample Calculations
with METS
Estimate of calories burned from 1 hour of
brisk walking in a 150 pound (70 kg)
person
walking = 6 METS = 6 kcal / kg / hour

6 kcal / kg / hour x 70 kg = 420 kcal/hour
22،03،16
Obesity and Lifestyle Modification
66
General Physical Activity
Recommendations
“Every healthy adult should accumulate 30
minutes or more of moderate-intensity
physical activity on most, preferably all, days
of the week”.
Surgeon General’s Report on Physical Activity and Health
22،03،16
Obesity and Lifestyle Modification
67
How Many Steps is Enough?
Activity Classification for Pedometer Step
Counts in Healthy Adults
Table 5, p. 104
Category
Steps / day
Sedentary
< 5000
Low active
5000-7500
Somewhat active
7500-9999
Active
10,000-12,500
Very Active
> 12,500+
Source: Based on values from Tudor-Locke, 2004.
22،03،16
Obesity and Lifestyle Modification
68
Pedometers




Pedometers provide a great way to remind you
to get more lifestyle physical activity in your day
(self-monitoring).
Set step goals based on 1 week of baseline steps
(average steps/day)
Increase step count by 1,000 to 3,000 steps/day
10,000 steps is NOT for everyone!
Accelerometer
22،03،16
Obesity and Lifestyle Modification
69
Lifestyle PA: Summary





Many advantages to adopting an active
lifestyle
You can accumulate lifestyle physical activity
throughout the day (10-min bouts) to meet the
recommendations
Many people use pedometers to self-monitor
daily activity levels
Changes in the environment can promote
lifestyle physical activity
Also need to consider personal strategies
22،03،16
Obesity and Lifestyle Modification
70
How To Achieve Weight Loss
1,000 – 1,200 kcal/day for women and
 1,200 – 1,600 kcal/day for men
 Reducing dietary fat along with
carbohydrates can facilitate calorie
reduction.
 Reducing dietary fat alone without reducing
calories is not sufficient for weight loss.

22،03،16
Obesity and Lifestyle Modification
71
How To Achieve Weight Loss

Physical activity is recommended as part of
a comprehensive weight loss program
because:
Contributes to weight loss
 Improved appetite regulation
 May decrease abdominal fat
 Increase cardio-respiratory fitness
 May help with maintenance of weight loss

22،03،16
Obesity and Lifestyle Modification
72
How to Calculate Energy Density




Energy Density = Calories/Grams
E.G. 150 Calories/100 grams = 1.5 Kcal/g
Energy density of 1 – Eat any quantity
Limit foods with energy density >2
22،03،16
Obesity and Lifestyle Modification
73
“Healthy Obesity”

Physically-fit obese patients have LOWER
mortality rates than unfit normal-weight
persons!
Being thin doesn’t guarantee being healthy
 Being fat doesn’t HAVE to be unhealthy


Physical activity and cardiovascular fitness
are much more predictive of health than
body weight
22،03،16
Obesity and Lifestyle Modification
74
Facts on exercise in obesity tx.
Exercise alone only leads to slight wt loss, if
any, but marked reduction in mortality
 Adding moderate/vigorous aerobic exercise to
dieting slightly increases wt loss
 Aerobic exercise during wt loss lessens loss of
FFM
 Resistance exercise during wt loss preserves
FFM and may help maintain wt loss
 Any type of exercise helps maintain wt loss, but
duration must be 4-10 hours/week
 Compliance may be better with multiple shortbout sessions Obesity and Lifestyle Modification
22،03،16

75
“A meta-analysis of the past 25 years of
weight loss research using diet, exercise,
or diet plus exercise intervention.”

Average 15-week treatment
 Diet or Diet-plus-exercise program, produces a
weight loss of about 11 kg

22،03،16
Miller WC, Koceja DM, Hamilton EJ. Int J Obs Relat Metab Disord 1998
Aug;22(8):825.
Obesity and Lifestyle Modification
76
“The effects of 18 months of intermittent vs.
continuous exercise on aerobic capacity, body weight
and composition, and metabolic fitness in previously
sedentary, moderately obese females.”

Two exercise groups:



Weight loss:



continuous (30 min, 3d/wk, 60-75% VO2max)
intermittent (brisk walking 15 min 2x/day, 5d/wk).
continuous group: -2.1%
intermittent group: none
Donnelly JE at al. Int J Obes Relat Metab Disord 2000
May;24(5):566-72.
22،03،16
Obesity and Lifestyle Modification
77
What is effect of resistance
exercise on weight loss?



None
Some studies even show weight gain
However, there may be some other benefits
22،03،16
Obesity and Lifestyle Modification
78
Does aerobic exercise vs. diet
alone alter the composition of
weight loss?

YES
Diet alone leads to marked reduction in FFM
as well as fat mass
 7 of 10 studies: aerobic exercise preserves
(FFM)
 Differences could be related to degree of
obesity


22،03،16
Higher BMI --> less FFM lost
Obesity and Lifestyle Modification
79
What is the effect of resistance
training on body composition?


Definitely preserves, and may even increase,
FFM
Unclear effect on fat mass
3 studies show more fat mass lost w/ Diet +
Resistance vs. Diet alone
 3 studies show no difference

22،03،16
Obesity and Lifestyle Modification
80
*
What role does exercise have in
weight loss maintenance?

An important role

Wing RR. Med Sci Sports Exer 1999
 Review of literature; 6 studies

22،03،16
4 of 8: significant long term differences favoring diet
+ exercise
Obesity and Lifestyle Modification
81
How much exercise is needed for
optimal weight loss maintenance?

The more, the better!
210 min/week brisk walking: 40% wt regain
 600 min/week brisk walking: 15% retain

22،03،16
Obesity and Lifestyle Modification
82
Resistance exercise DURING weight
loss may have a role in long-term
maintenance.

RCT, 20 kids/adolescents, 2 groups, 12 weeks
 Diet-only
 Diet + Resistance Exercise

Weight loss equal in both groups
Fat free mass decreased in diet-only
group
At one year f/u, wt regain inversely
related with fat free mass at 12 wks


22،03،16 
Schwingshandl J et al. Obesity
Effectand
of Lifestyle
an individualised
Modification training programme during
83
Response of obesity to exercise
may have a genetic component.


Study of obese patients in France
UCP3 gene



22،03،16
Wild C/C genotype: BMI was negatively a/w PA
(p=.015).
C-->T polymorphism: BMI not a/w PA
Otabe S et al. A genetic variation in the 5' flanking region of the
UCP3 gene is associated with body mass index in humans in
interaction with physical activity. Diabetologia 2000 Feb;43(2):2459.
Obesity and Lifestyle Modification
84
Treating Obese patients
(there is no one single best method)
22،03،16
Obesity and Lifestyle Modification
85
Treating obesity demands a multifaceted approach with chronic
monitoring
1.
2.
3.
4.
5.
22،03،16
Decreased caloric intake
Increased exercise
Behavioral modification
+/- Pharmacotherapy
+/- Surgery
Obesity and Lifestyle Modification
86
Goals of treatment

Get patients to look like models?


Get patients to their ideal body weight?


NOT practical usually
Get patients to lose 5-10% of body weight?


NOT
HOPEFULLY
Get patients to exercise and reduce their
mortality risk?

22،03،16
DEFINITELY!
Obesity and Lifestyle Modification
87
Set reasonable expectations



Gradually develop regular exercise
Gradually develop more healthy eating
Shoot for losing 5-10% of body weight first
22،03،16
Obesity and Lifestyle Modification
88
1. Decreased caloric intake

500 - 1000 kcal/day less than usual

Lose 1-2 lbs/week
National Heart, Lung, and Blood Institute. Clinical
guidelines on the identification, evaluation, and treatment
of overweight and obesity in adults: the evidence report.
1998.
22،03،16
Obesity and Lifestyle Modification
89
2. Increased exercise

Exercise regularly
Need to gradually work up to this
 Start with brisk walking 10-45 min, 3-5
days/week
 Work up to 60-80 min, most or all days/week
 Aim to expend 1,000 - 2,000 kcal/week

NHLBI, ACSM
22،03،16
Obesity and Lifestyle Modification
90
*
What kind of exercise is best for
obesity treatment?

May be a combination of aerobic AND
resistance training
22،03،16
Obesity and Lifestyle Modification
91
Counseling patients to increase
exercise

Use the 5 A’s of counseling:
Address the agenda
 Assess



Advise


22،03،16
Personalized exercise recommendations
Assist


Knowledge, beliefs, concerns, feelings, stage of
change
Provide support, identify barriers and resources
Arrange follow-up
Obesity and Lifestyle Modification
92
Example:
Counseling a patient in
preparation phase

Give specific advice on Frequency,
Intensity, Time and Type of exercise
(FITT)
22،03،16
Obesity and Lifestyle Modification
93
FITT Formula for Lifestyle Physical Activity
Threshold of Training:



Frequency: most/all days of week
Intensity: 55-90% of max heart rate
Time: 30-80 minutes
Gradually work up to this
 Start with brisk walking 10 min, 3-5
days/week
 Work up to 60-80 min, most or all days/week


Type: aerobic, resistance
NHLBI, ACSM
22،03،16
Obesity and Lifestyle Modification
94
Follow-up after initial counseling


See patient two weeks later and every month
Ask about progress


Ask about barriers



Encourage!
Discuss remedies
Weigh patient
Follow cholesterol, blood sugar, BP, etc.
15 ،18 ‫نوامبر‬
Obesity and Lifestyle Modification
95
3. Behavioral Modification





Self-monitoring
Stimulus control
Body image and self-esteem counseling
Stress management
Social support
22،03،16
Obesity and Lifestyle Modification
96
CBT Cognitive Behavioral
Therapy (CBT) and Obesity




CBT is a common type of mental health
counseling (psychotherapy)
CBT helps you become aware of inaccurate or
negative thinking
CBT may use relaxation techniques as well as
strategies to maintain a positive attitude. Studies
have found that patients with CBT tend to become
more active and do exercise
It can be an effective tool to help anyone learn how
to better manage stressful life situations
22،03،16
Obesity and Lifestyle Modification
97
Behavior modification
strategies, extended treatment,
and physical activity are
excellent predictors of weight
loss during treatment.
Foreyt JP, Goodrick GK. Evidence for success of
behavior modification in weight loss and control.
Annals of Internal Medicine 1993;119:698-701.
22،03،16
Obesity and Lifestyle Modification
98
Self-monitoring


One of the MOST HELPFUL TOOLS IN
OBESITY MANAGEMENT
Observation and recording of behaviors


Total calorie intake, fat grams consumed, food
groups used, situations that promote overeating,
amount/intensity of exercise, weight, body
composition, etc.
Provides patient objective feedback so
improvements can be made
22،03،16
Obesity and Lifestyle Modification
99
Stimulus control

Identifying and modifying the
environmental cues that are a/w overeating
and inactivity
Laying workout clothes on bed to increase
likelihood of exercise the next AM
 Eating only at kitchen table
 Avoiding situations where overeating common

22،03،16
Obesity and Lifestyle Modification
100
Body image and self-esteem
counseling

Many obese pts have poor self-esteem


Many have unrealistic wt loss expectations


Negative thoughts lead to poor compliance
Ideal body wt vs. 5-10%
Distorted body image

22،03،16
20% of obese pts won’t exercise because they
feel too fat
Obesity and Lifestyle Modification
101
Stress management



Stress is a primary predictor of relapse and
overeating
Management techniques are VERY effective
in obesity treatment
Refer to mental health professionals if not
skilled yourself
22،03،16
Obesity and Lifestyle Modification
102
Social support




Those with it have more success
Friends
Family
Community-based groups


Health clubs, education courses, Weight
Watchers
Church-related activities
22،03،16
Obesity and Lifestyle Modification
103
4. Pharmacological therapy

Candidates:
BMI 27-29.9 and + risk factor
 BMI >=30


Never use as sole therapy!!
Poor effectiveness
 Poor long-term maintenance of wt loss


Agents approved by FDA for long-term use
22،03،16
Obesity and Lifestyle Modification
104
Sibutramine (Meridia)





Blocks reuptake of norepi and serotonin
Appetite suppressant, ? thermogenic
Proven efficacy, even at one year of tx
Improves TC, LDL, TG, HbA1c
Side-effects:


Headache, elevated BP, insomnia, constipation,
dry mouth
Cost: $80/month
22،03،16
Obesity and Lifestyle Modification
105
Orlistat (Xenical)




Decreases fat absorption by inhibiting lipase
in intestine (not absorbed)
Proven efficacy, even long-term
Improves TC, LDL, TG, HbA1c, glucose)
Side-effects mostly GI:

Oily spotting, flatus, fecal
urgency/incontinence



Worse after fat ingestion; can lead to less fat eaten
Multi-vit with A/D/E/K recommended
Cost: $110/month
22،03،16
Obesity and Lifestyle Modification
106
5. Surgery for obesity

For high-risk patients who have failed nonsurgical therapy
BMI 35-39.9 w/ RF’s
 BMI >= 40




Produces longest wt loss maintenance of all
treatment methods
Significantly decreases mortality rate
Techniques: vertical gastric banding, gastric
bypass
22،03،16
Obesity and Lifestyle Modification
107
Summary of treatment based on
BMI and risk






BMI 25-30, no RF: advise wt loss
BMI 27-29.9, >= 2 RF: treat, +/- meds
BMI 30-35: treat, +/- meds
BMI 35-39.9, no RF: treat, +/- meds
BMI 35-39.9, + RF: treat; +/- meds;
consider surgery
BMI >= 40: treat; +/- meds; consider
surgery
22،03،16
Obesity and Lifestyle Modification
108
Facts on exercise in obesity tx.
Exercise alone only leads to slight weight loss,
if any, but marked reduction in mortality.
 Adding moderate/vigorous aerobic exercise to
dieting increases weight loss.
 Aerobic exercise during weight loss lessens loss
of FFM.
 Resistance exercise during weight loss
preserves FFM and may help maintain wt loss.
 Any type of exercise helps maintain weight loss,
but duration must be 4-10 hours/week.
 Compliance may be better with multiple shortbout sessions. Obesity and Lifestyle Modification
109
22،03،16

Review pearls







22،03،16
BMI > 30 defines obesity
Risk-stratify patients based on co-morbidity
Combined treatment with exercise, diet and
behavior modification is most effective
Set a reasonable goal of 5-10% wt loss
Start exercise slowly; emphasize benefits
even if it doesn’t result in wt loss
Follow-up frequently and monitor
Consider meds/surgery for high-risk
patients
Obesity and Lifestyle Modification
110
Conclusion:





Obesity is an increasing problem
Fitness is very important
Exercise and diet must be combined
weight loss strategies are not treatment
Exercise alone is important for reduction in
mortality
22،03،16
Obesity and Lifestyle Modification
111
THANK YOU FOR YOUR ATTENTION!
22،03،16
Obesity and Lifestyle Modification
112