CHAPTER 10

ENERGY BALANCE, WEIGHT CONTROL AND EATING

DISORDERSPART 2 OF 2

LEARNING OUTCOMES

• Describe the different methods to measure body composition.

• Describe the programs available to treat overweight and obesity.

• Discuss the characteristics of fad diets.• Be able to evaluate whether weight loss

programs are safe and likely to result in long- term weight loss.

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LEARNING OUTCOMES

• Describe the treatments that are available for more severe obesity.

• Describe the causes of, effects of, typical persons affected by, and treatment for anorexia nervosa, bulimia nervosa, and binge-eating disorder

• Explain methods for reducing the development of eating disorders, including the use of early warning signs to identify early cases.

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TREATMENT PYRAMID

Surgery

Pharmacotherapy

Lifestyle Modification

Diet Physical Activity

BMI

DO DIETS WORK AT WEIGHT LOSS?

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DIETDIET WEIGHT LOSS

COST

Weight Weight WatchersWatchers

5% in 6 5% in 6 monthsmonths

$167

VLCDVLCD 15-20% in 6 15-20% in 6 monthsmonths

$1700-2100

Internet-Internet-based based

1% in 6 1% in 6 monthsmonths

$65 (per 3 months)

Tsai and Wadden. Ann Intern Med 2005.

The average weight loss for high quality, state of the art weight loss diets is 10% in 6 months.

FAD DIETS

• Encourage rapid weight loss• Lean tissue and water loss occur

• Does not encourage behavior change• Weight loss is usually regained

• Low carbohydrate diets• Novelty diets• Quick fad diets

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TREATMENT OF OVERWEIGHT AND OBESITY

• 3 Key Components to Sound Weight Loss• Control of energy intake

• Fewer kilocalories• Low energy density diet

• Physical activity• Control of behavior problems

• Behavior modification techniques

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CONTROL OF PROBLEM BEHAVIORS: CHAIN BREAKING

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CONTROL OF PROBLEM BEHAVIORS: STIMULUS CONTROL

• What about your environment may be driving you to eat more or make poor choices?• Where?• What?• Why?

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CONTROL OF PROBLEM BEHAVIORS: COGNITIVE RESTRUCTURING

• Changing ones frame of mind about eating• Making “excuses” or justifying

unhealthy habits• Being very negative or hard on

yourself

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CONTROL OF PROBLEM BEHAVIORS: SELF MONITORING

• Tracking food intake, physical activity, and body weight

• Tracking emotions related to eating

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WILL THEY KEEP THE WEIGHT OFF?

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DIET LONG TERM WT LOSS

LONG TERM ATTRITION

RATE%

Weight Watchers

3.2% at 2 y 27% at 2 yr

VLCD 7.3% at 3.4 yr 42% at 3.4 yr

Internet 1.1% at 1 yr 34% at 1 yr

Tsai and Wadden. Ann Intern Med 2005.

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WHY IS IT SO HARD TO MAINTAIN WEIGHT LOSS?

IS IT EVEN POSSIBLE?

WEIGHT MAINTENANCE

• When you restrict calories for weight loss your body responds by reducing energy expenditure lower than one would expect for the new weight and body composition.

• Restricting calories also alters expression of hormones which increase hunger.

• EXERCISE can help prevent the above things from happening

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SUCCESSFUL WEIGHT MANAGEMENT: LESSONS

FROM THE NATIONAL WEIGHT CONTROL REGISTRY

•Registry members have lost an average of 66 pounds and kept it off for 5.5 years

– 90% exercise, on average, about 1 hour per day.

– 62% watch less than 10 hours of TV per week.

– 78% eat breakfast every day. – 75% weigh them self at least once a week.

CASE STUDY: RK AND THE FRESHMAN 40

• 19 yo female• 65 inches, 180 lbs, BMI 30• Wt history: weighed 140 (BMI 23.3) in HS. Also

played soccer and ran track.• Lifestyle: Stopped playing sports, lives in dorm,

busy schedule.• Goal: 120 lbs

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STEP 1: SET REALISTIC GOALS

–Substitute healthy weight for ideal or “dream” weight

–Loss of 10% of body weight (18 lbs or 162#)

–1-2 pounds per week (will take 9-18 weeks)

–Long term goal should be weight maintenance

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ASSESS EXPECTATIONS: WEIGHT GOALS

• Dream Weight• A weight you would choose if you could weigh whatever • Happy Weight• A weight that is not as ideal but would be happy to

achieve• Acceptable Weight• A weight you would not be particularly happy with, could

accept• Disappointed Weight• Less than current weight, but could not view as

successful in any way

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WEIGHT EXPECTATIONS

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Defined Weights % Reduction

Dream 38%

Happy 31%

Acceptable 25%

Disappointed 17%

After 48 weeks of treatment, 47% of patients did not achieve even a disappointed weight.

STEP 2: ASSESS DIET

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Time Food Kcal8am: Large coffee w/skim milk and splenda & protein bar

(220)1pm: Tuna salad wrap (700)3pm: Diet coke and bag of Baked Lays (200)7pm: 3 cups pasta with red sauce (650) 10pm: 1 slice pizza

(300)2070

STEP 3: DETERMINE ENERGY NEEDS

• Estimated calorie needs for RK: 1913 Calories/day

• Cut 500 calories/day to cut 3500 calories/week = 1 pound loss/week

• New calorie goal: 1413 (*not less than 1200 calories/week)

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STEP 4: MAKE NEW PLAN- CAN USE FOOD GUIDE WEBSITE HTTP://WWW.CHOOSEMYPLATE.GOV/

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Food group Amount Tips

Grains 5 oz 3 oz whole grain

Vegetables 2.0 cups VARIETY

Fruit 1.5 cups VARIETY

Dairy 3 cups Low fat

Protein 4 oz Lean

Oils 3 tsp Monounsaturated

Discretionary 100 calories Limit empty calories

STEP 4: MAKE NEW PLAN

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Time Food Kcal8am: Small latte w/skim milk& high fiber bar and banana (180)1pm: Tuna SW on whole wheat

w/lite mayo w/ cup of veg soup

(400)3pm: Water and yogurt (130)7pm: 1 cup ww pasta, 2 cup veg, 2 oz chix

(400) 10pm: Sundae from McD

(330)1440

FAST FORWARD 20 YEARS…

• Every January RK tried a new fad diet that produced a 10 lb loss followed quickly by a 15 lb gain.

• She now weighs 280 lbs (BMI 46.6) and has type 2 diabetes. She needs knee replacement surgery but because of other health conditions her Dr. tells her to lose weight first.

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Treatment Pyramid

Surgery

Pharmacotherapy

Lifestyle Modification

Diet Physical Activity

BMI

DRUG TREATMENT

• Subutramine or Meridia• Reduces hunger by changing some of the signals

in the brain (hypothalamus)• Phentermine

• Also reduces hunger by changing some of the signals in the brain (hypothalamus) and raises basal metabolic rate

• Orlistat, Zenical, or Alli• Blocks fat absorption by inhibiting lipoprotein

lipase• Other

• Anti depressant and anti seizure medications that reduce hunger

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INDICATIONS FOR WEIGHT LOSS SURGERY

1. BMI > 35 in association with major medical complications of obesity

ORBMI > 40

2. Failure of other approaches to long-term weight loss

ROUX EN Y GASTRIC BYPASSROUX EN Y GASTRIC BYPASS

•Small stomach pouch

•Alteration of food pathway

•Causes decreased hunger, increased fullness

•Average weight loss is 30% of initial weight

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ADJUSTABLE GASTRIC BANDING

•Small stomach pouch•Requires regular

adjustments and greater dietary monitoring

•Average weight loss is 20% of initial weight

•No change in food pathway

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EATING DISORDERS

Anorexia Nervosa

• Denial of appetite + poor body image

Bulimia Nervosa

• Binge followed by purge

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Who?

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EATING DISORDERS OTHERWISE NOT SPECIFIED (EDOS)

• Broad category to include partial symptoms of anorexia or bulimia

• Examples:• Meets all criteria for anorexia nervosa but

continues to menstruate OR whose weight is in normal range

• Meets all criteria for bulimia nervosa but binges less than twice/week OR does not binge OR spits out food

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EATING DISORDERS: TREATMENT

AN

• Nutrition• Gradual weight gain• Help choose healthy

food

• Psychological• Body image• Coping skills (control)

BN

• Nutrition• Emphasis on regular

meal patterns• Self monitor

• Psychological• Coping skills• All or nothing thinking

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EATING DISORDERS: PREVENTION

• Recognizing what’s normal and what is a red flag

• Treating any physical and emotional problems early

• Setting up children for positive body image, tolerance for all body types

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ALMOST EVERYONE IN MARY’S FAMILY IS OVERWEIGHT OR OBESE. SHE IS WORRIED ABOUT THIS AS WELL.

SHOULD SHE BE?

IS THERE ANYTHING SHE CAN DO TO AVOID EXCESS WEIGHT GAIN?

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ED DOES HIS PROJECT FOR HUMAN NUTRITION. HIS WEIGHT IS STABLE, BUT ACCORDING TO THE DIETARY ANALYSIS HE IS CONSUMING MUCH LESS THAN HE SHOULD BE.

WHY MIGHT THIS HAPPEN?

SHOULD HE INCREASE HIS CALORIES?

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