Guest guest Posted May 14, 2005 Report Share Posted May 14, 2005 Hi All, The pdf-available below is on CR goals for weight loss. CR is the topic almost as much as is weight loss. The topic of increasing physical activities is, in comparison, much less. Changing food choices appears to be important. Assessing hunger is also important. Changing behavior may be the bottom line. Also pdf-available, are the two papers in the issue referred to in the below: Bray GA, Champagne CM. Beyond energy balance: there is more to obesity than kilocalories. J Am Diet Assoc. 2005 May;105(5 Pt 2):17-23. PMID: 15867891 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstra\ ct & list_uids=15867891 and Schoeller DA, Buchholz AC. Energetics of obesity and weight control: does diet composition matter? J Am Diet Assoc. 2005 May;105(5 Pt 2):24-8. PMID: 15867892 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstra\ ct & list_uids=15867892 Nonas CA, GD. Setting achievable goals for weight loss. J Am Diet Assoc. 2005 May;105(5 Pt 2):118-23. No abstract available. PMID: 15867907 Research Case Study Applications in Practice Theoretically, the solution to weight gain is easy: alter the energy balance by changing the calories in and/or the calories out. But as Bray and Champagne (see page S17) indicate, the factors affecting this simple equation are numerous and complex and involve the interplay of the host’s genetic responses with an obesigenic environment. The clinical issue, then, is determining how those who are genetically susceptible to this toxic environment learn to manage their weight in the course of day-to-day living. The purpose of this case study is to show how the clinician’s skills can help the patient adjust behaviors in order to better defend against this environment and follow a healthier lifestyle. As Schoeller and Buchholz’s review (see page S24) on diet composition in this issue suggests, the jury is still out as to whether macronutrients matter. Thus, independent of macronutrient composition, any diet that creates an energy deficit will produce weight loss. Successful weight management will likely require daily vigilance and the creation of new skills as life changes. How, then, does the clinician help patients build and maintain weight-management skills? The difficulty lies not in the diet per se, but in adherence to the diet. Most dieters lose weight and regain; very few actually know how to maintain. The average dieter needs a diet that will “recharge” them and then has to remain vigilant and recover from lapses forever. Making adjustments in lifestyle means constant reassessment of life’s changes. The dietetics professional, therefore, has to be empathetic, behaviorally focused, and knowledgeable enough about physical activity to encourage and advise. Professionals also need to be creative and flexible enough to help inspire, and forceful enough to help the patient stay accountable and live within patient-centered goals (1–3). She or he also has to know when to let go, if the match between dieter and dietetics professional is not working. The following case description is about JB, a woman who will have one profile but two scenarios, based on her socioeconomic status (SES), in order to show how a dietetics professional might help guide a patient differently, depending on the patient’s needs and abilities. JB’s profile JB is a 38-year-old woman and single parent of a 12-year-old daughter. She works full time. JB smoked cigarettes in her early 20s and restarted recently to help her with stress and overeating. She says that she smokes only three cigarettes per day and will stop as soon as she loses weight. She drinks alcohol on occasion, although with all the new data on one drink a day being healthful, she finds herself drinking more frequently. She has no allergies to food or to medicine. Initial visit This is JB’s first appointment with the registered dietitian (RD). Although JB was told to bring her latest laboratory report and a progress note from her physician, all she has is a note on a prescription pad stating that JB needs weight loss. Between work and her life as a mother, she has not had a lot of time for herself, and finds that she has gained weight, her cholesterol is high (242 mg/dL), and her blood pressure is labile (today it is 140/88 mmHg) but she does not know how high it goes. JB is 5 feet, 5 inches, 195 lb with a body mass index (BMI; calculated as kg/m2) of 32.8, which is obese (class 1). Because the BMI is <35, a waist circumference is indicated (4). The initial visit takes place in the winter. JB, who is embarrassed by her body, balks when she is asked to take down her stockings and pants in order for the RD to do an accurate waist circumference. It is not uncommon for an obese person to display reticence in showing body parts because body image dissatisfaction is almost universal (5). The RD is sensitive to this and defers a waist measurement. Although the National Institutes of Health guidelines support the taking of waist measurement for anyone with a BMI & #8804;35 (4), JB’s BMI of >30 is indicative of class 1 obesity and is itself a risk factor for concomitant disease. Although not scientifically based, as clinicians it has been our decision to measure waist circumference only if the BMI is <30 or if the patient is disrobing anyway in the course of the medical visit. The importance of the waist circumference is still discussed, as is the suggestion that JB consider doing it at home. The clinician explains how it is done and suggests that JB report back with her results. JB denies symptoms of sleep apnea. Her periods are normal and she does not appear to have unwanted facial hairs, symptoms that might indicate polycystic ovary syndrome. She does not remember doing a glucose tolerance test or a hemoglobin A1c or liver function tests, but she says that her doctor told her not to worry about her glucose—that everything was normal except cholesterol. This is confirmed to the clinician by the physician in a telephone conversation. Family history JB’s father has diabetes and hypertension, but JB thinks that he is otherwise healthy. At first, JB states that neither parent is overweight but upon more detailed questioning, she explains that her father was overweight and recently lost some weight to improve his diabetes. JB has one sister who is older with a weight and height similar to JB’s. Weight history JB was 135 lb throughout college. During her marriage, when she was 23, she gained another 10 lb. Postpregnancy she was 150 lb. It was in the last 10 years that she gained 45 lb. She feels it is stress—the combination of her job and her divorce—that have caused her to be this heavy. Even so, when the dietetics professional discusses her “obesity,” there is a disconnect for JB. She knows she is overweight, but obese? JB feels frumpy, she feels unsexy. She does not think of herself as obese. Words such as weight or excess weight might be more acceptable to patients (6). Diet history She has tried a number of diets, all of which have done her well for short periods of time. She is vague on just how many or for how long, but she tried Weight Watchers (at least two times), SlimFast, Herbalife, Ma Huang, Diet Tea, and some over-the-counter products that she cannot remember. She also went to a physician who gave her urine injections and tenuate. Currently, she is at her highest weight. Physical activity Other than activities of daily living, JB has no physical activity, although she states that she used to be a lot more active and means to start soon. Assessing energy consumption and expenditure When the clinician does a dietary recall, it sounds as if JB eats very well. As Kushner and Blatner review (see page S53), there are three ways to assess diet: food journal, food frequency questionnaire, and typical day. The RD makes a habit of asking all new patients to bring in a week’s food record, but during the initial visit, the patient is also asked for a typical day. The reason for this is simple: a food record may turn out to include better choices because the patient is recording it, or it can be done sloppily because the patient is resurrecting it at the end of the day, or inaccurate because the patient’s portion sizing is distorted. A balance of a food record and a dietitian’s skill in asking open-ended questions (3) to get a picture of a typical day may represent a more realistic picture (Figure). In some patients, a thorough diet history may elucidate a pattern of behavior that sets the patient up for overeating. For example, the person who goes back and forth into the kitchen at night to nibble—if the kitchen is cordoned off after dinner, weight loss may result, even though no change in food choices has been discussed. It is our belief that, as is the case here, a combination of a typical-day food recall and an actual food record is a good start to help patients reduce daily calorie consumption. The difference between her record and her recall gives the dietetics professional a chance to see where the vulnerabilities in her eating lie. With this information, the dietetics professional can help JB think through the best way to reduce calories. Is it imperative to assess JB’s maintenance calories in order to help devise a diet for weight loss? Clinicians have debated the accuracy of an application of predictive formulas (7). Here is the dilemma: Even assuming an accurate estimate of energy expenditure, the vagaries and imprecision of calorie counting will make it difficult to accurately calculate consumption. How then, is the patient able to consume 500 to 1,000 calories less than her total energy expenditure to achieve a 1- to 2-lb weight loss each week? Maybe JB can calculate the calories in a turkey sandwich, but how does she calculate the calories in her takeout Chinese food or in the casserole that she has at her friend’s house? When someone loses 1 to 2 lb per week, is it that they are accurately counting calories or is it because they are more consciously doing without certain types of food and monitoring their intake? How the clinician and the client deal with this depends upon the comfort level and skills of each person. For example, if the client is meticulous and enjoys detailed recording, then calculating calories may be very helpful. In that case, the clinician may give the client an estimated calorie expenditure and subtract 500 to 1,000 calories from the result [eg, and Benedict (8) and Mifflin and colleagues (9)], or explore the use of a metabolic cart (eg, Sensor Medics [Yorba , CA]) or handheld devices (eg, HealtheTech [Golden, CO]) to actually measure resting energy expenditure (REE). Predictive equations for REE tend to over- and underestimate, especially among the obese (7). Changing food choices If JB were drinking a lot of high-calorie drinks, such as smoothies, coffee concoctions, or even juice or alcohol, then it might be easy to reduce her calories by having her drink only zero-calorie drinks. Or, if she was eating a muffin from the coffee cart for breakfast, then we could save 600 calories just by changing the food choices. But this is not the case with JB. Her incidental eating of birthday cake or one cookie gives us hints about what she does, but there are no facts. There are clearly some pitfalls in what JB chooses to eat. Between the recall and the typical day, the clinician can see that JB tends to eat healthful meals, but likes sweets as snacks. There are also no fruits and few vegetables on either dietary day. Even if JB’s meal choices are healthful, it is possible that her ratio of foods on the dinner plate is not conducive to losing weight. For example, it may be that JB’s portion of rice is too big and the vegetable portion is too little, resulting in more calories than she realizes. But this is potentially nitpicking, something that might not fare well with JB. Instead, in order to reduce calories, it may be helpful for JB to develop certain strict policies about eating, such as eating only fruit or vegetables between meals, or not eating bread at lunch, or drinking an over-the-counter meal replacement for breakfast. These types of goals are measurable and specific. It is straightforward to assess whether they were accomplished or not. If they are successful, it is useful to examine how JB achieved this success. If the modifications were not successful, then barriers to goal attainment can be reviewed (3). In order to gain a clearer picture of JB’s eating, the clinician might have had JB do a food record for 1 or 2 weeks without any modifications. JB might lose weight just by paying attention, but the main goal would be to give both the clinician and the patient a clearer idea of the normal eating pattern. Although more information is a valid goal, it might not be enough for JB to feel as if she received the guidance she was looking and paying for. Assessing hunger It is often the case that dieters will know the basics about a healthful diet, but are unable to see the food choices or the triggers that set them up to overeat. Two helpful strategies for patients like JB are assessing hunger and making specific behavioral changes. Although two separate issues, they are often intertwined. To assess them, it is helpful to divide JB’s day into three parts (morning, afternoon, and evening). That way, if there are no problems in one part of the day, the clinician can suggest no change, making JB feel less overwhelmed, as if she did not have to overhaul every hour. When asked if she is hungry in the morning, JB states that she is never hungry at breakfast and she believes that what she eats for lunch is not predicated on whether she has breakfast or not. This is a predicament, as data from the National Weight Registry (Hill and colleagues, page S63), suggest that those who eat breakfast tend to maintain a weight loss better than those who do not eat breakfast. Yet, if JB is not hungry for breakfast, and it does not impact her lunch, why add the calories? When asked about the afternoon, JB admits that she tends to get hungry in the late afternoon but she is not sure if it is hunger or fatigue. However, she always either snacks in the middle of the afternoon or comes home and eats too much while she is preparing dinner. If she works late at the office, she often eats whatever is around coworkers’ desks before she goes home. It makes sense that JB might be hungry in the afternoon, given that the time between lunch and dinner is the longest for JB, and that if she does not have a snack, it may set her up for overeating while she is cooking or ordering dinner. Therefore, this is a time when a substantial snack or mini-meal may be helpful. Although JB’s dinner meal sounds healthful, her after-dinner eating pattern is often when JB is most vulnerable to overeating. This is true for many people, as they unwind from the stresses of the day. There are many distractions: at home it is television, the computer, daily chores, fatigue; away from home there is restaurant food, alcohol, and social distraction. “Incidental calories” can add up and become the most damaging of any part of the day. When asked if she is hungry, JB freely admits that she is not, she is just tempted by the kitchen. Changing behavior One of the first issues that we have to grapple with is the issue of smoking. Although JB has reduced her cigarette smoking to approximately three per day, it is still important to address it. It is a particularly difficult issue because of the fear of weight gain. Although most will gain less than 4.5 kg, as many as 13% of quitters may gain at least 11 kg (10). However, most of the weight gainers have smoked more than JB is currently smoking. JB agrees that she needs to stop altogether, but asks to do it over a month’s time, which seems reasonable. First scenario: JB—higher SES JB is a partner in a law firm. She works long hours and has a housekeeper who stays late with her daughter when needed. If JB comes home before 7 PM, the housekeeper leaves and JB will cook dinner for her and her daughter. If she comes home later, the housekeeper will cook dinner for JB’s daughter and when JB comes home, she will eat whatever is left over from her daughter’s dinner or order out. In reality, she will do both, as she waits for her takeout, she will nibble mindlessly on leftovers. The rest of the evening is spent doing chores, helping her daughter with homework, and watching television. On Saturdays, she usually goes out to dinner. JB has private insurance but medical nutrition therapy for weight loss is not reimbursed. JB will receive some money (out of network) for the initial visit to the dietitian because she has high cholesterol, but after that, she will pay out of pocket, subtracting it from her flexible spending plan that she has at her office. The plan is for JB to come weekly for the first 4 weeks and then every other week for follow-up visits. The mere process of a weekly meeting and food recording should help JB focus (see Berkel and colleagues, page S35) and give the clinician the opportunity to show JB where her vulnerabilities lie. During the first session, the focus is on hunger and choices. Because of JB’s busy lifestyle, she needs something easy, quick, and monotonous. If JB has to mull over a menu or debate with herself, choice will become too difficult. Instead, to assuage JB’s late-afternoon hunger, it is agreed that she will drink an over-the-counter liquid formula. At an average of 220 calories per can, it is usually used as a meal replacement, but in this case, it may work to stave off hunger in between meals. The can of liquid does not tempt her the way a formula bar might and she likes the idea of an “absolute.” Also, the drink gives JB some extra calcium and vitamins, which she needs. On days when she will be out of the office, JB’s secretary agrees to pack one bar in JB’s briefcase as needed. JB also agrees to have a bag of baby carrots and baby tomatoes in the house for her to nibble on when she gets home. In that way, she has addressed her two main hunger times. A behavioral plan now needs to be designed to reduce the after-dinner risks. The first suggestion is a food record, but JB balks, saying it is too much trouble and she knows she will not do it. This is important to consider. Although the data clearly show that food records help, a tool for weight loss is two-pronged: it has to be useable and then it has to be effective. If the patient will not use it, it will never be successful. So the clinician and JB work together to design something that JB is willing to try. They agree that counting the number of times JB goes into the kitchen at night might be just as effective as a food record, but easier and different. The food record will look like this: Food Pattern Record The goal is for JB to stop going into the kitchen after dinner, for anything, even a glass of water. That way, once she breaks the habit, if she goes into the kitchen for anything, even a carrot stick, she will be more aware of what she is doing. JB also agrees not to eat while watching television (she decides this would be good for her daughter as well). Over 4 weeks, she sees the clinician the agreed upon four times and loses 10 lb. Over the next month she sees the clinician twice (also agreed upon), and loses only 1 lb. The following month she does not come at all—business meetings make her cancel both scheduled visits. After the fourth month, JB regains 2 lb. At this point, JB needs to recommit. It may be that she needs more intensive therapy, or that she is becoming bored. And it is typical to reach a plateau at about this time (11). The dietetics professional suggests that JB hire an exercise specialist to come to her home three mornings each week to help her get into the exercise groove. JB balks at the potential outlay of money, so the RD suggests that they change their schedule during that time: JB will try the exercise specialist for a month, but keep in touch with the dietetics professional by e-mailing her every Monday as much of a food record as she is able to muster, and schedule a visit at the end of the month. Although the clinician charges for e-mail, the combination of e-mail, frequent appointments with the exercise physiologist, and once-per-month nutrition visits ends up only slightly more than what she was paying before starting her diet and she can still use her flexible spending plan to reimburse the outlay of money. The combination of a new focus on her body, the accountability through e-mail, and something “new” help JB return to her 10-lb weight loss. Treating adult obesity can also have positive collateral effects on children because the parent can model healthful behaviors. Some of JB’s behaviors and changes in diet may lead to healthful lifestyle changes for her daughter as well. As Ritchie and colleagues (see page S70) and Kirk and colleagues note (see page S44), there is a significant association between hours spent watching TV and obesity. Changes such as reducing TV and limiting eating to non-TV areas would be healthful changes for both mother and daughter. Likewise, increasing physical activities that both can do together will increase energy expenditure, while giving the parent and child quality time together. Second scenario: JB—lower SES JB works as a medical office technician in the local hospital. She has union insurance. Her job is 8 AM to 4 PM every day. She has no extra money. She brings lunch to work every day, but there are a lot sweets in the office that she snacks on throughout the afternoon. She comes home and cooks for her daughter and herself. On weekends, she runs errands and watches a lot of television. The union has given her two nutrition visits, and that is all she can afford. The medical profile is the same as the original one. JB wants to lose weight but her attempts at weight loss have been short-lived. Because of the few visits available, the dietetics professional and JB have to find very specific ideas that can be instituted quickly and clearly. In this case, JB and the dietetics professional need to make all the suggestions for change in one visit so that in the second visit, there is a chance for review and adjustment. Four behavioral plans are developed. 1 Because she gets hungry in the late afternoon but not in the morning, JB agrees to break her lunch into two lunches by adding a piece of fruit and some raw vegetables to her lunch. She can eat half of her sandwich at lunch with the fruit and eat the other half in the late afternoon with vegetables, in order to reduce snacking due to hunger. It is also a way to improve her nutritional picture. JB likes this idea because she gets to eat something substantial and she does not have to think about it. 2 JB also agrees to chew gum (which she does anyway) at particularly strategic moments, such as when she is walking through the office in the afternoon or when she is cooking for her daughter at night. For example, if JB wants to taste what she is cooking, she will have to take the gum out of her mouth, making the incidental eating more salient. 3 JB will put music on in the evening for a half-hour after dinner and dance with her daughter. This will add some activity, reduce television watching, give her quality time with her daughter, and help change the automatic behavior of eating after dinner while watching TV. 4 Because dinner is the hardest for her to manage, JB will try to cook two vegetables for every meal, visualizing her plate as half-filled with vegetables, thereby controlling the portions of other foods. These are a lot of changes for JB, but she is willing and eager and the RD formalizes it by typing them up and sending them to JB’s home as a reminder. The RD also suggests that JB join Weight Watchers, which happens to have a site at her place of work. Weight Watchers has been shown to be effective (12,13), is less expensive than medical nutrition therapy visits, and will help keep JB accountable. The next visit with the dietetics professional is scheduled for 6 weeks, but to ensure that these behavior changes are initiated, JB agrees to call the clinician twice: once in 3 days to let her know how things are progressing and again 2 weeks later to field any small problems that may arise. JB calls in 3 days. She is implementing the agreed-upon behavioral changes but is concerned because she is still hungry at the afternoon snack. So the dietetics professional suggests two possibilities. One suggestion is that she eat yogurt and fruit at lunch and her whole sandwich as an afternoon snack. Another is that JB have her sandwich as she always did, but have cereal and milk as an afternoon snack. This way she can be eating breakfast in the afternoon and it might satisfy her hunger and her appetite. JB likes the cereal idea. Two weeks later when she calls, it has worked. However, she has still not joined Weight Watchers. Six weeks later when she returns for her visit, she is 5 lb less, and she just joined Weight Watchers the week before, knowing that she was seeing the dietetics professional. This is the last visit for JB, but she believes there is a lot more work to do and wants to petition her insurance company for one more visit. An appointment is scheduled for 3 months later, giving JB room to cancel if she needs to, but keeping her focus on her health in the meantime. JB feels as if she knows what to do, but would have liked a little more guidance. The dietetics professional also gives JB a list of Web sites she can access to get more support. JB does not have a computer at home, but can go to the library when she needs to. She agrees to try to get her daughter to go as well, and that will give them both an opportunity to use the library more often. Summary These cases reflect the need for dietetics professionals to be flexible when helping patients manage their weight and to acknowledge that not every eating problem can be solved, no matter how many visits are available. Small, specific goals can help lead to small successes, and small successes lead to big successes. As Reeves and colleagues (2) suggest, there are five guiding principles in helping patients change eating habits: • Flexibility on the clinician’s part; • Assessment of health status and weight loss effect on health status; • Improvement of nutritional status; • Keeping the big picture criteria for success “on the table”; and • Producing weight loss. In order to do that, we have to consider JB’s future. Although her reimbursement opportunities are limited, the clinician gives her a letter to send to her insurance company to appeal for more visits. The clinician also gives JB a list of programs and Web sites that may be viable alternatives for the support she needs to continue losing weight. Self-help programs such as Overeaters Anonymous and Take Off Pounds Sensibly, Web sites such as SlimFast, Web programs such as ediets, or group meetings such as Weight Watchers may be helpful on a limited budget. Finally, the local department of health offers free aerobic classes in a park near her home, which may also give her an opportunity to increase her calorie expenditure. No matter what scenario, JB has left the dietetics professional’s office feeling successful. She has lost weight, improved her blood pressure to normal range, reduced her serum cholesterol by 20 points (not far enough, but a good start), and improved her nutritional picture. If clinicians expect more than that in the short-term, it may be unrealistic. The long-term clinical challenge is to establish a link with JB so she feels safe to return when, not if, life gets in the way and she regains some weight. Keeping the door open in a nonjudgmental fashion may be among the best things we can do for our patients. Al Pater, PhD; email: old542000@... Stay connected, organized, and protected. Take the tour: http://tour.mail./mailtour.html Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You are posting as a guest. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.