The American College of Sports Medicine (Donnelly 2009) reports that some individuals require even more exercise (150–250 minutes per week of moderate-intensity physical activity) just to prevent weight gain. If our normal routine of work and/or play does not regularly include this amount of activity, we must either intentionally commit to an exercise routine or live with the bulges that store this unspent energy. Of adults over 19 years of age, an average of 46% met the 2008 recommendations for aerobic exercise and 21% met both aerobic and muscle-strengthening recommendations in 2010. Participation in physical activity was lower than this among women, older adults, and minorities (CDC/NCHS 2011).
Chapter 4
Treatment Options
As the rate of obesity increases, so has our appreciation that this condition is complex. The age-old approach to weight loss—calories consumed must be balanced against calories expended—is not incorrect but is far from complete. Genetic susceptibility and environmental encouragement have joined forces to boost consumption and minimize activity, accelerating the incidence and consequences of excess body weight. Several tools, supported by medical research, are available for fighting excess weight. However, tools alone assist but do not solve the problem. Sustainable weight loss still requires that the number of calories out surpasses the number of calories in. To accomplish this, we offer information and support on how to change, teach the basics of meal planning, and invite everyone to move more and sit less. If these patient-driven activities are insufficient, drug therapy and bariatric surgery may be appropriate adjuncts.
WHO (2007) and NHLBI (2010) describe methods that address caloric balance. The stated goal is to reduce energy intake so that it is lower than calories burned during the weight-loss phase and to rebalance caloric intake to match calorie expenditure during the weight-maintenance phase. Successful long-term weight loss has been defined as an intentional 10% weight reduction from baseline that is maintained for one year (Wing 2005). To reduce calories eaten or to increase calories burned requires change.
Lifestyle Change
Behavioral treatment is an essential component of any credible obesity treatment program (Berkel 2005, Foster 2004). Besides addressing the explicit problem behavior, behavioral treatment also addresses the ideas and emotions associated with having and changing behavior (Foster 2005). The primary targets for lifestyle change are eating habits and physical activity levels. However, changing behavior is, by itself, a skill that must be learned. Learning how to change is akin to learning how to learn. Once established, those skills offer the individual the power to keep changing and learning in the future. Successfully making changes is much more likely if people experience support for their efforts as well as guidance. Because obesity is a chronic condition, gaining skill and confidence in how to change behavior is vital to sustained weight loss.
The Core Features of Behavioral Treatment
• Observation. Self-monitor eating habits and physical activity.
• Stimulus control. Identify and limit exposure to cues that prompt overeating.
• Cognitive restructuring. Identify and modify unrealistic goals and inaccurate beliefs about weight regulation.
• Social support. Identify others who can help support your behavior change efforts.
• Problem solving. Address issues related to eating and physical activity.
• Relapse prevention. Engage in maintenance of the achieved weight loss. Reevaluate setbacks and view these as learning experiences rather than failures.
Behavioral treatment can also include stress management (NHLBI 1998) and support for balanced and flexible food choices instead of structured diets as a means to improving nutrition (WHO 2000).
Meal Planning
“Meal planning” replaces the term “diet” and refers to the professionally recommended plan for improving someone’s dietary intake. Such plans are based on portion sizes, nutrient composition, and food distribution intakes that are likely to facilitate weight control. However, the actual meal plan as devised with a patient may only identify specific actions to help move the usual eating pattern toward a recommended one. Examples may be to add an apple to lunch, include a late afternoon snack, and/or switch from soft drinks to tea or water. Many patients benefit from more structure (calculated meal plans, recipes, prepared food) or simplified meals (a week of menus), especially in the beginning. People often have much to learn about how to select and prepare food. The work we do with a patient to devise an eating strategy is called meal planning.
Meal planning is an essential component of all weight-management strategies. A plan that somehow lowers caloric intake is typically necessary for weight loss, but this does not necessarily mean that an individual will always need to consume a smaller amount (volume) of food or actually count calories. Plans can change. The goal, as always, is to devise a meal plan that fits the individual who plans to use it.
Core Considerations for Building Meal Plans
• Space food intake to fuel energy needs and avoid excess hunger
• Limit portion size and frequent snacking
• Choose foods that supply nutrients, which contribute to health by:
+ Eating a variety of foods from all of the food groups
+ Emphasizing high-fiber plant food: whole grains, fruits, vegetables, cooked dried beans, nuts, seeds, etc.
+ Choosing lean protein
+ Minimizing saturated and/or trans fat intake
• Consume adequate non-caloric fluids
Sources: USDA/USDHHS 2010, NHLBI 2005
Physical Activity
According to the 2008 Physical Activity Guidelines for Americans, health improves with at least 150 minutes of aerobic activity and two days of strength training per week. Specifically, guidelines recommend that, for good health, people set as their weekly target 150 minutes (30 minutes for 5 days) of moderate-intensity aerobic activity (i.e., brisk walking) and muscle-strengthening activities on two or more days per week (CDC 2011b). Recommendations suggest that everyone benefits from both aerobic and muscle-strengthening activity. This assumes type, intensity, and duration match individual needs. Appropriate exercise may require professional guidance, especially for those with physical limitations/disability.
Additional exercise is probably required to support weight-loss efforts. Moderate-intensity physical activity for 150–250 minutes per week provides modest weight loss, which can be improved with modest (but not severe) diet restrictions. Physical activity greater than 250 minutes per week is more likely to result in clinically significant weight loss (Donnelly 2009). Although resistance training does not significantly enhance weight loss, it does increase loss of fat mass and improves health risks with or without weight loss. Because muscle burns calories, increasing muscle mass increases calorie needs.
There is evidence that ongoing physical activity helps maintain weight loss (Cooper 2001, Hill 2005). Although the amount required varies greatly from person to person, it is likely that as much as or more (>250 minutes per week) physical activity is required to maintain weight loss (CDC 2011a). Currently, there is no evidence from randomized controlled trials to document physical activity effectiveness to prevent regain (Donnelly 2009).
Although the impact of exercise on weight loss may be modest, both the International Diabetes Federation (IDF 2010) and the CDC (2011a) recommend increased physical activity for weight loss. Exercise as part of a comprehensive weight-loss therapy and weight-maintenance program may decrease body fat and increase lean muscle (U.S. Department of Health and Human Services 2005a,b), as well as offering cardiovascular and other health benefits. Unfortunately, the short-term costs of sacrificing