Weight Loss and Weight Management: Current

Theories and Best Practices

Presented by the
Western Region Public Health Training Center &
the Southwest Telehealth Resource Center
© 2015 UA Board of Regents
Welcome
WRPHTC region – Arizona, California, Hawai’i,
Nevada, and the US Affiliated Pacific Island
SWTRC region – Arizona, Colorado, New
Mexico, Nevada, and Utah
Fellow HRSA grantees
All other participants from the US & abroad

© 2015 UA Board of Regents

Continuing Nursing Education Information

Series Purpose
The purpose of the Weight Loss and Weight
Management: Current Theories & Best Practices series is
explore and describe the components of a successful
weight loss and management program for children and
adults in family and community practice settings.
 Continuing Nursing Education Information

Learning Objectives

Upon completion of this presentation, the participants will be able to:

1.Identify the 3 levels of Physical Activity Guidelines that affect patients with
obesity

2.Define NEAT and describe the difference and impact of moving from sedentary to
light activity

3.List the Exercise Rx Top Ten

 Continuing Nursing Education Information

Nursing Evaluations & Disclosures

Criteria for successful completion:

• Attendance requirements
• You must be present and logged into the webinar by 12:10 PM (Arizona
time)
• Complete an online NURSING evaluation
• Available online at: cne.nursing.arizona.edu/evaluations
• Deborah Horn has declared a financial relationship with Novo
Nordisk, Takeda, Eisai. All other planners and presenters have no
relevant financial relationships to declare.
Webinar Series
Weight Loss and Weight Management: Current Theories & Best Practices
This four session, interactive webinar series brings together national leaders in
nutrition, exercise and bariatric medicine who will address what is needed to
have a successful weight loss and management program for children and adults
in family and community practice settings. The series will start with a
presentation and discussion on dynamic energy balance, an important new
perspective on what metabolic changes occur during weight loss and how
these changes have to be taken into account as part of a weight loss program.
The second session will focus specifically on exercise and energy expenditure
and weight loss. The final two sessions will present pediatric and adult case
studies to highlight the promoters and challenges that lead to successful
patient care, in regards to weight loss and maintaining weight loss.

© 2015 UA Board of Regents

Webinar Tips & Notes
• Mute your phone &/or computer microphone
• Time is reserved at the end for Q&A
• Please fill out the post-webinar survey
• Webinar is being recorded
• Recordings will be posted on the SWTRC website (http://www.southwesttrc.org)
and the WRPHTC YouTube channel (https://www.youtube.com/user/azphtc)

© 2015 UA Board of Regents

“Rethinking Energy Balance: Applying Science
to Practice”

Deborah Bade Horn, DO, MPH, FASBP

Clinical Assistant Professor
Department of Surgery
University of Texas Medical School in Houston

© 2015 UA Board of Regents

Affiliations/Background
Medical Director, COMMP
Center for Obesity Medicine & Metabolic Performance
University of Texas Health Science Houston, Texas
Clinical Assistant Professor, Department of Surgery
UT Health Science Center Houston, Texas
President-Elect and Fellow - American Society of Bariatric Physicians
Diplomate - American Board of Obesity Medicine
Board Certifications: Preventive Medicine and Family Medicine
Dual Master’s Degrees
Exercise Physiology
Public Health and Physical Activity
“Results Typical”

Weight Maintenance
&
Metabolic Health
Road Map
 “Results Typical”:
The Guidelines for Physical Activity
Setting your patient up for success!

 Physical Activity + Overweight/Obesity 101

Quick tools to improve your approach to PA
Mets and Obesity
Anti-Sedentary Strategies
Equipment and PA Tracking
Winning with Muscle & Metabolism
5 Most Common Recommendations for PA

A. Wait until you are at your goal weight. Right

now just focus on your diet
B. Walk 30 minutes per day 5 days per week
C. Take the stairs and Park your car farther away
D. Join a Gym
E. No Pain, No Gain

What’s your PA Rx for a patient with obesity?

How Much Physical Activity is Enough?

General Health Benefit

 Moderate aerobic exercise
150min/wk (About 30 minutes
5x/wk) + Strength Training

Prevent Weight Gain &

Active Weight Loss
 150-250 minutes per week
 150-300 minutes per week

Prevention of Wt Regain
 200-300 minutes per week
 300-420 minutes per week Donnelly J. Am College Sports Med. 2009.
US Health and Human Services. 2008.
 Success & Physical Activity

Concomitant Behavior Therapy

Weekly Biweekly Monthly
0
Change in Weight (kg)

-2 <150 min/wk
-4
-6
-8 >150 min/wk *P<0.05
-10
-12 >200 min/wk
-14
-16
0 6 12 18
Time (months)
Jakicic JM. JAMA. 1999.
Look AHEAD Year 4: Success & PA

4-5 Mets for

60-70min/d
Or
Approx
420min/wk

Wadden TA. Obesity. 2011.

 Next Steps
 FFM preservation
 17 Observational Studies – (RYGB 31%, BPD 26%,
Band 18% loss of FFM)
 3.62 kg greater mean wt loss
 Self reported
 2.3x greater odds of
questionnaires
unsuccessful wt loss if  PA
after surgery  RCTs needed
 PA repeatedly an  Optimal Rx unknown*
independent predictor of  Excellent Review: King and
weight loss Bond. Exerc Sport Sci Rev., Vol
41(1) 2013
Physical Activity Recs & Bariatric Surgery
Pre-op Post-op
ASMBS: Mild exercise ASBMS/TOS/AACE:
20min/d, 3-4d/wk
At least 30 min/d
AHA: Low-Moderate intensity
IOM, HHS, ACSM, IASO: All
PA at least 20 min/d, agree that 150min/week is
3-4d/wk insufficient for the prevention
of weight regain.

ASMBS/ACSM expert panel 250-420min/wk

assembled to develop specific
pre/post operative recommendations.
60-90min/day

http://s3.amazonaws.com/publicASMBS/GuidleliStatesments/guildelines/asbs_bspc.pdfnes
Poirer et al. Circ 2011, Mechanick et al. Obesity 2009
Donnelly Med Sci Sport Ex 2009, IOM 2002
Saris et al Obes Review 2003,
http://www.health..gov/paguidelines/pdf/paguide.pdf
Time, Perception, Guidance, Barrier Removal…

 Only 22% of patients of Bariatric

Surgical Centers accredited by
the American College of
Surgeons (ACS) Bariatric
Surgery Center Network
(BSCN) report having received
postoperative exercise
consultation.
 Despite BSCN accreditation
requirements to establish
procedures for exercise
counseling.

Peacock JC, Zizzi SJ Surg Obes Relat Dis. 2012 Nov-Dec;

8(6):777-83.
 Exercise for Weight Maintenance
0 Exercise
Exercise

Weight Loss/Gain (kg)

2 Non-Exercise
Non-Exercise

10

12

14
1 2 3 4 5 6 7 8 8 18
Treatment (Weeks) Follow-Up (Months)
Pavlou KN. Am J Clin Nutr. 1989.
Physical Activity & Mets...What’s your intensity?
MET Categories

Light < 3 METs

Driving your automobile = 2

Moderate = 3-6 METs

Walking 4 mph, brisk pace = 5

Vigorous > 6 METs

Carrying 25-49pds upstairs = 8
Cardiorespiratory Fitness by Age & BMI

Byrne et al. J Appl Physiol 2005 Sept 99:1112-1119

 RPE Scale
Correlates with HR

Adapted from Borg RPE Scale

Gunnar Borg 1998
Physical Activity: Now or Later?

 Initial Activity > Initial Weight Loss

 At 12 mo., weight loss was similar.
 Physical Activity resulted in greater improvement in waist
circumference and hepatic fat content
JAMA. 2010 October 27; 304(16): 1795–1802
 Can we find more time to be active?
(2003–2006 NHANES survey)

Owen N et al. Br J Sports Med 2014;48:174-177

Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
Don’t just stand there……or maybe - Do!

Duvivier BMFM, Schaper NC, Bremers MA, van Crombrugge G, et al. (2013) PLoS ONE 8(2): e55542.
Br J Sports Med. 2014 Feb;48(3):213-9
How can work spaces change?
Individual Strategies
 STAND UP  MOVE MORE
– Set a timer (Outlook, Up, Phone) – Active lunch breaks
– Stand up when someone enters the office – Fill water bottle/pick up printing
or phone rings – Use the stairs!
– Stand up when someone else does – “Let’s do a walk”
 SIT LESS – Active transport errands
– Predetermine “Standing Times” like after – Take a commercial break
lunch, morning, last hour of day.
 Think Outside the Treadmill
– Standing meetings
– What interests you?
– Is there a way to make it less sedentary and
more active?
– Can you do it and stand?
Engineering PA Back into Life
Realistic Resources
Low Risk, High Yield Physical Activity Tools

© Horn 2012
 Chronic Disease Data Tracking
 Pedometers
 Accelerometers
 Smart Scales
 Data Tracking by phone/computer
 Platform Connectivity
 Trainers, Physiologists, & Therapists..Oh My!
Trainers/Physiologists
Highly Recommended:
Graduate Level training
ACSM, NSCA or ACE = Nat’l Certs
CSEP Equivalents
Subspecialized Certifications

Physical Therapists
– Key role in orthopedically
complicated patients
– Revisit periodically
Expose Unexpected Barriers
Does your doctor visit look like this…….
In clinic, at home, on the road……
They will rise to the
occasion!
Markers for Success
BMI

Normal
Overweight Class I Class II Class III
Weight
25.0-29.9 30.0-34.9 35.0-39.9 >=40
18.5-24.9

Waist
Circumference
Abdominal
Obesity

Men >40in Women >35in

Percent Body (>102cm) (>88cm)
Fat

Essential Fat Athletes Fitness Acceptable Obesity

W 10-13% W 14-20% 21-24% W 25-31% W >/= 32%
M 2-5% M 6-13% M 14-17% M 18-24% M >/= 25%
Beyond BMI
 Weight, % Total Weight, % Excess Weight
 BMI
 Waist Circumference
 Body Composition
– Percent Body Fat, Visceral Fat
– Fat Free Mass or Skeletal Muscle Mass
 Edmonton Obesity Staging System
 Future Responder Biomarkers
Resting Metabolic Rate
Regression Equations
Mifflin St Jeor – No more than +/- 10% in at
least 70% of measurements
9% overestimations, 21% underestimations
Horie-Waitzberg – specific to severe obesity
Indirect Calorimetry
Inexpensive
Non-Invasive
Reimbursable
Presurgical, Postsurgical
intervals and at goal.
Horie et al Clin nutr 2008
www.andevidencelibrary.com
Main Influencers of FFM loss during calorie restriction

Heymsfield et al. Obesity Reviews 2014

Quarter FFM Rule
 “Approximately 1/4th of weight lost will  Delta FFM/Delta W
be FFM.” – FFM =majority in early phase (5-26 days)
– At best quarter FFM is an – FM = majority in late phase (300days in patients
approximation and appears to with obesity)
underestimate.

 Initial FFM - The leaner the subject is the greater

 Fat Free Mass loss is not constant
the FFM loss when placed in negative energy
but varies over time with larger
balance. (Forbes Rule)
changes observed earlier.
– Diet related weight loss body
composition differed between early
and later phase of food restriction.

Heymsfield et al 2011 and 2014

Keys & Brozek 1953
Grande 1961
Moderators of Fat Free Mass
Physical Activity + no caloric Aging
restriction Disassociation of ΔFFM from ΔW in
– reduction in FM with no or children with obesity during weight
small increases in lean tissues
management and growth
Physical Activity + calorie
FFM loss = 1.5kg/decade
restriction
– whether cardio or strength cuts “ Considerable loss of FFM is
FFM loss approximately in half. expected…to attain the expected body
composition at the lower BMI. 35-40%
Inactivity leads to FFM loss in men. 30-35% in women

Low CHO
< Low Glycemic Chaston et al 2006, 2007
Le Blanc et al 1992
<Low fat Forbes et al 1999
Body Comp Analysis, Obesity, & Surgery
 Rapid weight loss results in significant FFM loss.  18% reduction in FFM following surgery places
most patients in a state of cachexia.
 Increased FFM loss is related to negative clinical
and nutritional outcomes.  Some researchers have reported that up to a 20%
loss is “acceptable.
 Variation in tissue hydration and abnormal body
geometry may affect results if using Bioelectrical  De Freitas et al reported that 20% of total weight
Impedance lost following RYGB was FFM loss and
– Overestimation of FFM corresponded to malnutrition.
– Underestimation of FM
 Single frequency BIA is likely insufficient for
 Dexa Scans – gold standard, not feasible for monitoring Body composition changes in patients
repeated measures in clinical practice and table with obesity.
weight issues.

Ferreira et al. Nutrition 2013

Carey et al Obes Surg 2006
Waki et al AM J physiol 1991
Coppini et al Curr Opin Clin nutr Metabl Care 2005
Can we protect FFM during obesity treatment?
Initial Body Composition  26yo male: 7 month
Intensive Lifestyle
Intervention + Anti-
Obesity Medicine
 37.4lbs =
13% TBW
32% EBW
7 mo Follow-up Body Composition
 0.9 lb of muscle
mass loss = 2% of
total weight loss was
FFM.
 *25% FFM loss
would have been
>10x this.
Can we defend RMR & decrease visceral fat?

 7 months of
medical ILI + AOM.

 Initial RMR 2275kcal/d

 F/up RMR 2290kcal/d

 25% reduction in
Visceral fat.
Can we protect FFM during obesity treatment?
Initial Body Composition  58yo female: 11 month
Intensive Lifestyle
Intervention + Anti-
Obesity Medicine
 114 lbs =
43 % TBW
11 mo Follow-up Body Composition 110% EBW
 5.5 lb of muscle mass
loss = 4.8% of total
weight loss was FFM.
 *25% FFM would have
been 28.5lbs
Can we protect FFM during obesity treatment?

 11 mo of medical ILI +
AOM

 Initial RMR 1973kcal/d

 7mo RMR 1598 kcal/d
58lbs of SMM

 67% reduction in
Visceral fat.
Physical Activity and Obesity
Treatment……

Constructing a whole new road!

Questions?

[email protected]
Weight Loss and Weight Management Webinar Series

Next Webinar, Monday, October 12, 2015:

Pediatric Bariatric Case Study

Dr. Wendy Scinta
Medical Weight Loss of New York

Please check our website

http://www.telemedicine.arizona.edu/app/distant-
education/upcoming-workshops

© 2015 UA Board of Regents

 Your opinion is valuable to us.
Please participate in this brief survey:
https://www.surveymonkey.com/r/WRPHTCwebinar

This webinar is made possible through funding provided by Health Resources and Services Administration, Office for the
Advancement of Telehealth (G22RH24749) and is supported by the Health Resources and Services Administration (HRSA)
of the U.S. Department of Health and Human Services (HHS) under UB6HP27880 and Affordable Care Act (ACA) Public
Health Training Centers. This information or content and conclusions are those of the author and should not be construed
as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.
© 2015 UA Board of Regents
 Continuing Nursing Education Information

In order to earn 1.0 contact hour of

Continuing Nursing Education credit for
completing this presentation, fill out an
evaluation found at:
cne.nursing.arizona.edu/evaluations