1. Creighton Family Practice Birgit Khandalavala

2. Weight Management All members of the medical team are equipped to help patients with weight loss and management-these compromise, physical therapists, dieticians, nursing staff and physicians- team effort. Modest Weight loss is easily done and most patients would be able to lose 5-10% of their excess weight- Modest Weight loss is easily done and most patients would be able to lose 5-10% of their excess weight- Keeping it off is the key

3. Why do we gain weight? Multifactorial Genetic conditions are rare Obesogenic environment is the chief cause-FOOD IS A TOXIN Factors involved are neuro-endocrine, behavioral and Physical Activity One lifesaver extra a day- one pound per year- 10 pounds per decade

4. WEIGHT WEIGHT GAIN IS DUE TO MORE CALORIES BEING CONSUMED THEN EXPENDED BASAL METABOLIC RATE + THERMIC EFFECT OF FOOD + PHYSICAL ACTIVITY (INCLUDES “NEAT” AND PHYSICAL EXERCISE) Where the weight rests may be the most crucial factor-

5. The adipocyte Central fat cells are the most metabolically active producing hundreds of chemicals Inflammation is caused by these chemicals damaging the lining of blood vessels The more the number of these cells the more the resistance to weightloss- Overweight folks do not necessarily eat more that their thinner colleagues.

6. Emerging hypothesis A calorie is still a calorie But what the body is genetically programmed to do with that calorie is crucial May be converting extra sugar into fat and depositing this centrally as oppossed to to a more peripheral less toxic location Fat intake does not put on more fat

7. WEIGHT MANAGEMENT DIET BEHAVIORAL CHANGE PHYSICAL ACTIVITY- NOT ONLY EXERCISE BUT NEAT- CAN ACCOUNT FOR 30% MORE CALORIES BURNED- IT’S GOOD TO FIDGET( LEVINE ET AL) WE CAN NOT REALLY CHANGE OUR GENES – THRIFTY GENE MAY BE TO BLAME somewhat

8. Modalities “TRIM” FOR LIFE Healthy THOUGHTS and ROUTINES have to become a habit - no diet works - one most try something upto 30 times before it can even become close to a routine INTAKE has to be closely monitored Food journals are one of the key components MOVEMENT- not only exercise but any activity (Moderation- avoidance of calorie dense foods)

9. Putting it into action Multipronged approach incorporating Nutrition - low carbohydrate, higher protein high fiber diet along the lines of South Beach, Mediterranean diet, weight watchers, superfoods - tries to eliminate simple carbohydrate SUGAR. Encouraging good fats, complex carbohydrates and high fiber with non animal based protein

10. Behavioral changes Avoiding mindless munching’ Smaller portions- probably the most important aspect- use a salad plate not a serving platter Eating small frequent meals Food journals - pieces of paper to elaborate online clubs and cell phones Recording mood, emotional eating, identifying binge eating - can account for 30%

11. Pharmacology Using weight neutral medications Eliminating medications that produce weight gain - antidepressants, oral steroids, antipyschotics Substitution when possible Short term use of certain appetite suppressants if behavior and physical activity modifications are initiated - Meridia and Xenical are approved for the long term Treating insulin resistance early

12. Low calorie diets Using the optifast system Has to be closely supervised Outcome may be the same as the less dramatic behavioral based programs A weight loss of 2-4 pounds a month is excellent- especially if kept off

13. How Much to keep off 5% is great- 10% is better Keeping off 5-10% has enormous medical benefits

14. Surgery For BMI of over 40 or 35 : with co-morbidities Can help pre-operatively as well as post-operativerly - 5 step Creighton Weight management program is in place intense medically supervised program

15. In the clinic setting Patient evaluated for all the comorbidities - from head to toe - including liver enzymes, diabetes and hypertension, to reduce the risk of cardiac disease, certain cancers and potentially even alzheimers. Assessment for Sleep apnea. Focus not only on weight reduction but on decrease in body fat and especially reduction of waist measurement - goal is less than 35 inches in women and 40 inches in men (Caucasian) May turn out to be the single most important parameter.Marker of insulin resistance and precursor of diabetes etc.

16. Working with your provider How ready are you to change How motivated are you Realistic expectations- 5-10% with diet and exercise and a comprehensive program Additional 5-10% with medication More frequent contact has been the key to long term weight maintenance-programs are looking at 1-2 years. Group support, family involvement is crucial-TOPS,WW Do not focus alone on weight but other parameters as well.Be prepared for setbacks,plan ahead.Lifelong struggle- so make it a habit.

17. National weight control registry Hoping to enroll patients in this ongoing study of what works for thousands of patients online registry. Has to lose at least 30 pounds and keep it off for one year. Meanwhile eat breakfast, exercise 45 mins. a day at the very least, and eat small frequent meals with constant self monitoring- it works Good luck to TRIM for life.