1. The Solution: You and a little knowledge
Frank J. Domino, M.D.
Jill Grimes, M.D.
Barbara Olendzki, RD, MPH

2. Barriers to nutritional counseling
Confusion over current guidelines
Lack of time & compensation
Effectiveness of interventions
Confusion: nutrition as it relates to disease
GOAL: 5 Brief Concepts to Recommend

3. The National Weight Control Registry
“Successful Losers”
The National Weight Control Registry
>5000 successful losers
Members lost an average of 66 lbs (range= lbs) x 5.5 years (= 1 lb/month x 5 years)
78% eat breakfast every day.
75% weigh themselves at least once a week.
62% watch < 10 hours of TV per week.
90% exercise, about 1 hour per day.
Does wt loss work? Can MD’s make a difference?
The National Weight Control Registry
 The National Weight Control Registry (NWCR), established in 1994 by Rena Wing, Ph.D. from Brown Medical School, and James O. Hill, Ph.D. from the University of Colorado, is the largest prospective investigation of long-term successful weight loss maintenance. Given the prevailing belief that few individuals succeed at long-term weight loss, the NWCR was developed to identify and investigate the characteristics of individuals who have succeeded at long-term weight loss. The NWCR is tracking over 5,000 individuals who have lost significant amounts of weight and kept it off for long periods of time. 3 3

4. What about the average person? Daily Practices
Survey 2004 US > 18 Yrs. “Successful Weight Loss Maintainers”
Eat Fast Food < 2/Week
> 5 Fruits & Vegetables/day ** AND
150 Minutes physical activity (25 Min/Day)

5. 5 Steps to Healthy Diet Increase Fiber
Increase Water 16 Oz before meals
Prescribe Exercise
Eat MINDFULLY
Limit Screen Time to < 10 Hr/week

6. Increase Fiber
24 Hour Dietary Recall

7. “Tell me everything you ate and drank yesterday, starting with breakfast.”
NOT
Yesterday

8. Count Fruit and Vegetable Servings
Goal: 10 servings/day
25-30 Grams of Fiber
Min: 5 servings/day (15 Grams/Day)
Potatoes, Pasta &White Rice do NOT count
OK,
Now
You Count

9. 2. Water: Rx: WATER for Children
32 Elementary Schools, 2nd/3rd Graders (2950) children x 1 Yr
“Socially Deprived areas” Germany
Water Fountains + 4 lessons
Overweight: Int=3.8% vs. 6.0%
1.1 glasses/day more (220 ml)
Pedia 2009; 123(4): e661
Objective: The study analyzed the effect of a combined environmental and educational intervention solely promoting water consumption on the incidence of overweight among school children. Methods: 2,950 second and third graders of 32 elementary schools in socially deprived neighborhoods of two German cities participated in a randomized controlled intervention trial (August 2006-June 2007). In intervention schools (N = 17), water fountains were installed, each child received a water bottle, and teachers performed classroom lessons to promote water consumption. Control schools (N = 15) did not receive any intervention. Body heights and weights were measured at baseline and follow-up to assess the incidence and remission of overweight and obesity during follow-up. The water flow of the fountains was measured regularly during follow-up. Children's beverage consumption was self-reported in 24-hour recall questionnaires before and after intervention. Results: After the intervention, the incidence of overweight was significantly lower in the intervention group (3.8%) than in the control group (6.0%, p = 0.018). Remission of overweight and obesity did not differ between the groups. Measured water flow of the fountains indicated a sustained use. Conclusion: A simple dietary intervention with the sole focus on the promotion of drinking water effectively reduced the incidence of overweight among school children. 9

10. Water Consumption and Dieting for Adults
RCT over 12 weeks of adults
Compared Low Calorie Diet (LCD) vs. LCD + 16 Oz water prior to each meal
44% RRR (~4.5 Lbs) greater weight loss in Water group.
Obesity. 2010; 18(2): 300-7

11. Apples to Oranges… 1 Orange 40 8 Oz OJ 120 8 Oz Cola 100
Calories
1 Orange
8 Oz OJ
8 Oz Cola 100
Coffee Black
Coffee + 2 Sugar 30
Coffee + 1 Oz Cream 100
Staryucks Café Mocha 400

12. 3. Prescribe… EXERCISE 6300 adults Observational Study
Dx: Sed Lifestyle HTN, DM, OB, M/Skel
“Inactive” Baseline = 33%
At 3 Months= 17%;
At 12 Months = 20%
BMJ 2008: 337:a2084
Scandinavian Journal of Medicine and Science in Sports, doi: /j x
WALK
A study of 6300 patients who were given primary care prescriptions designed to improve their levels of activity shows that the proportion of inactive patients dropped from 33% to 17% after three months 12

13. How Much and What Kind of Exercise????
No one knows what is ideal for weight loss.
For CHD: Min Aerobic exercise 5 days/week.
For Weight loss:
Aerobic + Anerobic/Weight training 5 days per week
No “after exercise treat”

14. High Intensity Interval Training 4 Minute Work Out
Tabata (1996) Alternating High Intensity Exercise with brief episodes of rest
Anything that increases HR: Jump Rope, Run, Rowing Machine, Stairmaster/Treadmill
Tabata : 20 Seconds of FULL EFFORT Aerobic
10 Seconds REST x 8 cycles-> ↑ VO2 Max
Little: (2009): 60 Intense, 75 Rest x 8-12 cycles
3 x/week = 5 hours per of Aerobic

15. Most important part of long term weight loss and maintenance
Eat Mindfully
Increase in awareness of Eating
Most important part of long term weight loss and maintenance
Divide Plate in Half before eating, and at ½ point, ask “Am I still Hungry?”
Eat at table, not TV or paper
Medical weight loss is our goal. Not to manage ideal body weight. Resolution of co-morbidities and reduction of health risks are our main focus. 15

16. 5. Limit Screen Time Pediatric & Adolescent Literature
> 10 hrs/week ↑ Risk of Obesity & T2DM
Journal of Public Health (2):
Changing Sedentary to Active Screen Time Weight Loss
PEDIATRICS; (6) e1831-e1835

17. Obesity: A Chronic Disease
Analogous to diabetes & alcohol abuse
Requires daily maintenance
Planning
Overcoming “cravings”
Self Image Adjustment

18. Drugs: Looking to 2011…..
Orlistat: (Xenical) Inhibits Pancreatic Lipase ->↓ Intestinal Fat Absorption
6.5 lbs x 12 months
Sibutramine (Meridia): may reduce appetite
(24 Kg x 1 Yr; no better than placebo; x = 9 lbs)
NEW Options:
Qnexa: (phentermine 15 + topiramate 92 mg)
14% over 56 weeks
Contrave: (bupropion naltrexone 32mg)
5-7% BW over 24 weeks
Locaserin: Serotonin agonist
~3% weight loss at 1 year

19. Summary MI in 4 Steps Establish rapport & Elicit Change Talk: OARS
Open questions
Affirmations
Reflections
Summarize
Develop Discrepancy to Facilitate change talk using Rulers
Offer advice
End the interview with a plan

20. SUMMARY Steps to Healthy Diet
Increase Fiber: 24 Dietary Recall
Increase Water 16 Oz before meals
Prescribe Exercise
Eat MINDFULLY
Limit Screen Time to < 10 Hr/week

21. Motivational Interviewing for Weight Loss & Exercise
Frank J. Domino, M.D.
Professor