Module 5 PRACTICAL APPLICATIONS IN FOR NATALIE DIGATE MUTH, MD, MPH, RDN, FAAP

¢ OVERVIEW OF FEDERAL DIETARY GUIDELINES AND NUTRITION RECOMMENDATIONS

¢ BEST PRACTICES IN NUTRITION AND WEIGHT MANAGEMENT

¢ AN OVERVIEW OF POPULAR DIETS

¢ CULTURAL CONSIDERATIONS

¢ WEIGHT-LOSS SUPPLEMENTS

¢ SUMMARY 2 WEIGHT MANAGEMENT ( or useofvettedtools such asMyPlate(www.ChooseMyPlate.gov ) andSupertracker supporting aclientin makinghealthfulchoicesbasedonfederal dietaryguidelines recommendations from aregistereddietitian(RD),whileatother timesitmayinclude changes tooptimizehealth.Inmanycases, thismayincludehelpingtosupport enhance aclient’s self-efficacyand environmentalsupportstomakelastingdietary to nutrition,theprimaryroleofaweightmanagement specialistishelpingto highlighting bestpractices,challenges,opportunities, andgaps.Whenitcomes is nutrition.Thismodulefocusesontherole ofnutritioninweightmanagement, Many factorsplayaroleinweightand management.Perhapsthemostcritical risks aredecreased. people achieveandmaintainahealthyweight,oratleastweightwherehealth this morethanaweightmanagementspecialist,whoseworkdependsonhelping and obesitycanbedevastating.Nooneappreciates health consequencesresultingfromexcessweight normal weight(Yang &Colditz,2015),andthe Americans haveobesitythanareoverweightor Enterprises, 2013;Krugeretal.,2004).Yet, more , spendingover60billiondollarsperyearonweight-lossproducts(Marketdata millions ofAmericans.Considerthis:25%menand40%womenareona EFFORTS TOCONTROLWEIGHTANDBODYSIZEIMPACTTHEEVERYDAY LIVESOF www.supertracker.usda.gov) . a healthyweight achieve andmaintain Helping people

3 WEIGHT MANAGEMENT M are found in seafood, nuts, seeds, and oils. are foundinseafood, nuts,seeds,andoils. fats aremonounsaturatedfatandpolyunsaturated fat,which protein sourcesthatarehighinsaturated fat.Thehealthiest and plantproteinsratherthanredmeats orotheranimal and addedsugars.Thebestprotein sourcesareleanmeats peas, vegetables,andfruitsratherthanfromrefinedgrains natural, unprocessedfoodssuchaswholegrains,beans, risk (Table 5-3).Thehealthiestcarbohydratescomefrom fat forbothoptimalhealthandreductionofchronicdisease of caloriesthatshouldcomefromcarbohydrates,protein,and Macronutrient DistributionRange(AMDR),forthepercentage of Medicinehasestablishedarange,knownastheAcceptable high endoftherangeisforaveryactiveperson.TheInstitute the lowendofrangeisforasedentaryperson,while table todeterminetypicalcalorieneeds(Table 5-2).Notethat The highlighted inTable 5-1. and recommendationsofthescientificcommitteeis committee.pdf. Abriefoverviewofthemainfindings scientific-report-of-the-2015-dietary-guidelines-advisory- health.gov/dietaryguidelines/2015-scientific-report/pdfs/ Guidelines AdvisoryCommitteeisavailableat: The completescientificreportofthe2015Dietary AND NUTRITIONRECOMMENDATIONS OVERVIEW OFFEDERALDIETARY GUIDELINES unfounded andunsubstantiatednutritionclaimsfads. guide clientstowardmeaningfulandhealthynutritionchanges,whilealsosteeringclearof offer a fairly detailed Dietary GuidelinesforAmericansofferafairlydetailed and generalnutritionrecommendationswillprovideafoundationuponwhichtohelp motivated tomakenutritionalchanges.Familiaritywiththefederaldietaryguidelines any clientswanttoloseweightandimprovetheiroverallhealtharehighly www. SCIENTIFIC ADVISORY COMMITTEE KEY FINDINGSOFTHE2015DIETARY GUIDELINES Table 5-1 a maximumof10%totalcaloriesfrom addedsugarsperday. sodium perday, lessthan10%oftotalcaloriesfromsaturatedfatperday, and sodium. Thegoalsforthegeneralpopulation are:lessthan2,300mgdietary healthy dietarypatternsthatarelowin saturated fat,addedsugars,and The DietaryGuidelinesAdvisoryCommittee encouragestheconsumptionof food labelingtotargethealthychoices. increasing familymeals,self-monitoringofdietandbodyweight,effective screen time,reducingfrequencyofeatingoutatfast-foodrestaurants, The followingindividualbehaviorchangesimprovehealthoutcomes:reducing the currentU.S.diet. more healthpromotingandisassociatedwithlessenvironmentalimpactthan legumes, nuts,andseeds,lowerincaloriesanimal-basedfoodsis A diethigherinplant-basedfoods,suchasvegetables,fruits,wholegrains, grains. and processedmeat;lowinsugar-sweetened foodsanddrinksrefined non-fat dairy, seafood,legumes,andnuts;moderateinalcohol;lowerred A healthydietarypatternishighinvegetables,fruits,wholegrains,low-or Two nutrients areoverconsumed:Sodiumandsaturatedfat fiber; potassium;andiron(foradolescentpremenopausalfemales) Underconsumed nutrients:VitaminsA,D,E,andC;folate;calcium;magnesium; and dairy, thatprovidethesenutrients. underconsumption ofkeyfoodgroups,suchasvegetables,fruits,wholegrains, Several importantnutrientsareunderconsumed.Thisisinpartdueto 4 WEIGHT MANAGEMENT Suppl., S78–S92. Suppl., S78–S92. Source: Reprinted fromU.S.DepartmentofAgriculture (2010).2010DietaryGuidelinesforAmericans.www.dietaryguidelines.gov c b a ESTIMATED CALORIENEEDSPERDAY BYAGE,GENDER,ANDPHYSICAL-ACTIVITYLEVEL Table 5-2   Estimates forfemalesdonotincludewomen whoarepregnantorbreastfeeding. physical activityassociatedwithtypicalday-to-day life. to-day life.Activemeansalifestylethatincludes physicalactivityequivalenttowalkingmorethan3milesperdayat4hour, inadditionto thelight physical activityequivalenttowalkingabout 1.5to3.0milesperdayat34hour, inadditiontothelight physical activityassociatedwithtypicalday- Sedentary meansalifestylethatincludesonly thelightphysicalactivityassociatedwithatypicalday-to-daylife.Moderatelyactivemeanslifestylethatincludes Acids, Cholesterol,Protein,andAminoAcids.Washington, D.C.:TheNationalAcademiesPress. inches tallandweighs126pounds.EERequationsarefromtheInstituteofMedicine(2002). DietaryReferenceIntakesforEnergy, Carbohydrate, Fiber, Fat,Fatty and adolescents,referenceheightweightvary. Foradults,thereferencemanis5feet10inchestallandweighs154pounds.Thewoman4 Based onEstimatedEnergyRequirements(EER)equationsusingreferenceheights(average) andreferenceweights(healthy)foreachgendergroup.Forchildren ACTIVITY LEVEL GENDER/ 76+ 71–75 66–70 61–65 56–60 51–55 46–50 41–45 36–40 31–35 26–30 21–25 19–20 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 Age (years) activity. Theestimatesareroundedtothenearest200 calories.Anindividual’s needsmaybehigherorlowerthantheseaverageestimates. Estimated amountsofcaloriesaneededtomaintaincaloriebalanceforvariousgenderandagegroupsatthreedifferentlevelsofphysical Britten, P. et al.(2006).Developmentoffoodintake patterns fortheMyPyramidFoodGuidance System.JournalofNutritionEducation andBehavior, 38,6 B MALE/SEDENTARY 2,000 2,000 2,000 2,000 2,200 2,200 2,200 2,200 2,400 2,400 2,400 2,400 2,600 2,400 2,400 2,400 2,200 2,000 2,000 1,800 1,800 1,600 1,600 1,400 1,400 1,400 1,200 1,200 1,200 1,000 ACTIVE MALE/MODERATELY 2,200 2,200 2,200 2,400 2,400 2,400 2,400 2,600 2,600 2,600 2,600 2,800 2,800 2,800 2,800 2,800 2,600 2,400 2,200 2,200 2,000 1,800 1,800 1,600 1,600 1,600 1,400 1,400 1,400 1,000 MALE/ACTIVE 2,400 2,600 2,600 2,600 2,600 2,800 2,800 2,800 2,800 3,000 3,000 3,000 3,000 3,200 3,200 3,200 3,000 2,800 2,600 2,400 2,200 2,200 2,000 2,000 1,800 1,800 1,600 1,600 1,400 1,000 FEMALE SEDENTARY 1,600 1,600 1,600 1,600 1,600 1,600 1,800 1,800 1,800 1,800 1,800 2,000 2,000 1,800 1,800 1,800 1,800 1,800 1,600 1,600 1,600 1,400 1,400 1,400 1,200 1,200 1,200 1,200 1,000 1,000 C / FEMALE ACTIVE 1,800 1,800 1,800 1,800 1,800 1,800 2,000 2,000 2,000 2,000 2,000 2,200 2,200 2,000 2,000 2,000 2,000 2,000 2,000 2,000 1,800 1,800 1,600 1,600 1,600 1,400 1,400 1,400 1,200 1,000

C /MODERATELY FEMALE 2,000 2,000 2,000 2,000 2,200 2,200 2,200 2,200 2,200 2,200 2,400 2,400 2,400 2,400 2,400 2,400 2,400 2,400 2,200 2,200 2,000 2,000 1,800 1,800 1,800 1,600 1,600 1,400 1,400 1,000 C /ACTIVE 5 WEIGHT MANAGEMENT Washington, D.C.:TheNationalAcademiesPress. Carbohydrate, Fiber, Fat,FattyAcids,Cholesterol,Protein,andAminoAcids. Source: InstituteofMedicine(2002).DietaryReferenceIntakesforEnergy, RECOMMENDED MACRONUTRIENTPROPORTIONSBYAGE Table 5-3 the carbohydrate, protein,andfatthatshouldbeconsumedinaday, basedon (see Table 5-3)canbeusedtoestimatethenumberofgrams multiplied bythepercentageofcaloriesfromeachmacronutrients Taken together, aperson’s approximatecaloricneeds(seeTable 5-2) Adults (19andolder) adolescents (4–18years) Older childrenand (1–3 years) Young children Dietary Guidelines. 9 calories).Thisclientshouldconsumethefollowing: 4 calories;1gramofprotein=andfat Next, convertcaloriestograms(1gramofcarbohydrate= protein, and20–35%fat.Forexample: 5-3, hisdietshouldconsistof45–65%carbohydrate,10–35% approximately 2,600caloriesperday, andaccordingtoTable According toTable 5-2,Carlosshouldbeconsuming Answers: Carlos shouldbeeatingeachday. to determinehowmanygramsofcarbohydrate,protein,andfat about duringyourone-on-onesessions.UseTables 5-2and5-3 adhere totheDietaryGuidelinesyouhavebeenteachinghim macronutrients heshouldbeeatingonadailybasisinorderto named Carlos,istryingtodeterminehowmuchofthethree One ofyourclients,a30-year-old moderatelyactiveman MACRONUTRIENT NEEDSSAMPLEPROBLEM Fat: 520calories/9=58grams Protein: 650calories/4=163grams Carbohydrate: 1,430calories/4=358 grams Fat: 2,600caloriesx0.20=520 Protein: 2,600caloriesx0.25=650 Carbohydrate: 2,600caloriesx0.55=1,430 CARBOHYDRATE 45–65% 45–65% 45–65% PROTEIN 10–35% 10–30% 5–20% FAT 20–35% 25–35% 30–40%

the MyPlatewebsite(www.ChooseMyPlate.gov). educational materialstosharewithclientsareavailableon half theirplatevegetablesandfruits.Freedownloadable eat amorebalanceddietbyencouragingpeopletomake calcium-rich foods).ThegoalistoinfluenceAmericans grains, accompaniedbyaglassofnonfatmilk(torepresent divided intofoursections:fruits,vegetables,protein,and easily understoodandimplementedgraphic—adinnerplate simplifies thegovernment’s nutritionmessagesintoan representing ahealthyeatingplan(Figure5-1).MyPlate effort totranslaterecommendationsintoactionisanicon this. Onetoolthatthefederalgovernmentemploysinan monitor dietaryintake.Severaltoolsareavailabletodo The is availableasan app. information forthousandsoffoods. Supertrackernowalso track physicalactivity, monitorgoals,andlookupnutrition track nutritionintakeandcompare it torecommendations, five foodgroups.Thewebsitealso allows forindividualsto recommended numberofservingstoeatfromeachthe (from 1,000to3,200caloriesperday)andaregiventhe are categorizedintooneof12differentenergylevels eating plantomeetcaloricneeds.Withinseconds,users weight, andphysical-activityleveltogetanindividualized usda.gov excellent meansofmonitoringintake.Atwww.supertracker. practice. Forinstance,thefreeUSDASupertrackertoolisan analysis ofdietaryquality, whilestayingwithinthescopeof available tohelptrackaclient’s intakeandprovidean is notqualifiedtoanalyzedietarylogs,therearetools While aweightmanagementspecialistwhoisnotanRD strongly encourage individuals to Dietary Guidelinesstronglyencourageindividualsto MYPLATE SUPERTRACKER , consumerscaninputtheirage,gender, height, MyPlate Figure 5-1 6 WEIGHT MANAGEMENT AND WEIGHTMANAGEMENT BEST PRACTICESINNUTRITION maintenance, several best practices in nutrition and weight management have emerged over time. maintenance, severalbestpracticesinnutritionandweightmanagementhaveemergedovertime. experts donotknowyetaboutweightlossandweight-loss is arelativelyyoungfieldofstudy, andthereisalotthat information constantlyemerging.Althoughnutritionresearch J overpredicts . overpredicts weightloss. expenditure) changesandtheequationbecomeslessaccurate loss, asanindividuallosesweight,metabolism(andthusenergy the equationof3,500caloriesperpoundisusefulearlyoninweight becomes muchmoredifficult.Whilepredictingweightlossbasedon weeks ormonthsandseveralpoundslater, continuedweightloss a clientcouldloseaboutpoundperweek,fortime.Afterfew taking a45-minute,2.5-milewalkeachday(about250calories), drinking waterratherthana20-ozbottleofsoda(250calories)and loss perweek.Bymakingrelativelyminorlifestylechangessuchas increased physicalactivityleadstoabouta1-2-poundweight 1,000-calorie deficiteachdaythroughdecreasedfoodintakeand expended. Withabout3,500caloriesinapoundoffat,500-to a caloricdeficitsothatfewercaloriesareconsumedthan The goalofadietaryinterventiontodecreaseweightiscreate consequences thatcanresultfromexcessweight. many casesmaybe“goodenough”toavertoftheharmful and maintainthanhighlyaggressiveweight-lossgoals,in et al.,2013).Thisdegreeofweightlossismorefeasibletoachieve advocate foragoalof5to10%weightlossinsixmonths(Jensen Larger weightlossleadstoevengreaterimprovements.Experts decrease manyoftherisksassociatedwithoverweightandobesity. of weight,evena3to5%weightlosscanimprovehealthand While manypeoplemayaspiretoloseasubstantialamount WEIGHT-LOSS PREDICTIONS related to nutrition and weight is ongoing, with new related tonutritionandweightisongoing,withnew understanding ofnutritionforoptimalhealth,research ust astheDietaryGuidelinesareupdatedeveryfiveyearstoreflectadvancesin each poundlostwillcomefrommuscle. topreservemusclemass,aboutone-fourthof that allweightlosswouldcomeonlyfromfat.Without to maintainmusclemass,andeventhenitisunlikely a clienthastoexercise(especiallyresistancetraining) all fatandnomuscle.Inorderforthattobethecase, Of course,thisequationsupposesthatweightlostis 3,500 caloriesperpoundoffat. commonly roundedto3,500,anditissaidthatthereare 3,600 calories/pound.To makeitsimple,thenumberis 400 gramsoflipid,and9calories/gramx= one poundof“fat”storedinthebodyisapproximately body as85to90%lipidand1015%water. Therefore, While 1poundoffatis454grams,storedinthe not 3,500calories. that multipliesoutto4,086calories—whichclearlyis (1 kg=2.2lb)andthereare9caloriespergramoffat, number comesfrom?If1poundoffatequals454grams 1 poundoffat,buthaveyoueverconsideredwherethis You maycommonlytellclientsthat3,500caloriesequals Equal 1PoundofFat? Doing theMath:HowDoes3,500Calories weight isongoing to nutritionand Research related

7 WEIGHT MANAGEMENT 20, daily energy expenditure decreases by about 50 calories per 20, dailyenergyexpendituredecreasesbyabout50caloriesper decrease intheamountofcaloriesburned.Infact,afteraboutage steady lossofmusclemassandgainfat,whichtranslatestoa (Flegal etal.,2012).Thatmaybeduetoadecades-longslowand the ageof60aremorelikelytohaveobesitythanyoungeradults and theweightgaindoesnotstopinmiddleage.Infact,adultsover 25-year-old womanislikelytobecomea143-pound45-year-old— is likelytobecomea195-pound45-year-old, anda130-pound (Williamson, 1993).Thismeansthata180-pound25-year-old man 44 years,whiletheaveragewomangainsabout5%per10years 3% ofhisbodyweightduringeach10-yearintervalbetween25to the scaleineitherdirection.Afterall,averagemangainsabout balance caloriesconsumedwithexpendedtoavoidtipping Many peoplecurrentlyata“healthyweight”stillmaystruggleto accurately predictaclient’s anticipatedweightloss. simulator atbwsimulator.niddk.nih.gov of threeyears.Theresearchershavemadeavailableaweight-loss 25 poundsinthefirstyearandaboutmorebyend years. Ifshehadcreateda500kcaldeficiteachday, shewouldlose lowered caloric intake,andabout 10 more poundsby the end of three to 2,000calorieswouldloseabout10poundsafteroneyearofthe who decreasedherdailycaloricconsumptionfrom2,200calories achieved withinthreeyears(Halletal.,2011).Forexample,awoman half oftheweightlostbyoneyearand95%change intake, theaverageoverweightadultwillloseabout1pound,with changes. Theyapproximatethatforevery10-caloriedecreasein mathematical modeltomoreaccuratelyaccountforthesemetabolic A groupofscientistsattheNationalInstitutesHealthdevelopeda AVOIDING WEIGHTGAINOVERTIME , which you can use to more , whichyoucanusetomore metabolically activemusclemass. high levelofenergyexpenditure,andstrengthtrainingtomaintain engaging inregularcardiovascularphysicalactivitytomaintaina foods likevegetablesandleanproteins,moderatingcaloricintake, from decreasedmetabolismbyeatinglow-calorie,nutrient-dense inevitable, adultscanavoidtheaverageweightgainresulting While asmalldecreaseindailyenergyexpenditurewithagingis sleep andskippingbreakfast. calories, certainmedications,andunhealthyhabitssuchaslackof contributors includelowerlevelsofphysicalactivity, eatingtoomany this metabolicslowdowncanberesponsibleforweightgain,other increased fatmass(whichisrelativelymetabolicallyinactive).While to decreasedmusclemass(whichishighlymetabolicallyactive)and 50 inwomen(Roberts&Dallal,2005).Thisdeclineisprobablydue decade, withamorerapiddeclineoccurringafterage40inmenand 180,000 deaths each year (Singh et al., 2015). 180,000 deathseachyear(Singhetal.,2015). 2013) andoverallmortality, withsugarydrinksresponsibleforabout juices willreducetheprevalenceofobesityandtype2diabetes(Hu, of sugar-sweetened beveragessuchassodas,sportsdrinks,and clear thatachangesuchasreducingoreliminatingconsumption Since publicationofthispracticeguideline,italsohasbecome along withthedegreeofevidencesupportingeachstatement. factors studiedfortheguidelinereportarehighlightedinTable 5-4, nutritional considerations(Jensenetal.,2013).Key comprehensive guidelineonthemanagementofobesity, including Cardiology (ACC),andTheObesitySociety(TOS)publisheda The AmericanHeartAssociation(AHA),Collegeof NUTRITIONAL STRATEGIES TOLOSEWEIGHT 8 WEIGHT MANAGEMENT NUTRITION BESTPRACTICESFORWEIGHTLOSS:WHAT THEEVIDENCESUPPORTS Table 5-4 Cardiology/American HeartAssociationTask ForceonPracticeGuidelinesandTheObesitySociety. Circulation,publishedonlineNovember12,2013. Source: Jensen,M.D.etal.(2013).2013AHA/ACC/TOSguidelinesforthemanagementofoverweight andobesityinadults:AreportoftheAmericanCollege Note: LDL=Low-densitylipoprotein;HDLHigh-densitylipoprotein women orwithobesity. Longer-term evidenceofcontinuedweightlossislacking. The useofliquidandbarmealreplacementsisassociatedwithincreasedweight lossat6monthsinoverweight Both high–andlow–glycemicindexdietsachieveasimilarweightlossover6 months. calories) whenbothdietsmaintaina500–750kcaldeficit. High-protein diets(25–30%oftotalcalories)causesimilarweightlossastypicalprotein(15% carbohydrate diets. Low-fat dietshavegreaterreductioninLDLandtriglyceridesasmallerincreaseHDLcomparedtolow- maintained. Both low-fatandlow-carbohydratedietsleadtocomparableweightlosswhena500–750kcaldeficitis kg (6.6to8.8lb)at2years which slowweightgainisobserved,withatotallossofabout4to10kg(8.822.2lb)at1yearand3 Weight lossachievedthroughnutritionchangesrangesfromabout4to12kg(8.826.4lb)at6months,after A varietyofdietaryapproachescanproduceweightloss. physical activity, regularbody-weightmonitoring,andconsumptionofareduced-caloriediet. The weight-lossmaintenanceinterventionshouldincludemonthlyormorefrequentcontactandanemphasison changes. Thebestprogramslastatleast6monthsandincludeaweight-lossmaintenanceinterventionafterwards. A comprehensiveweight-managementprogramshouldincludebehavioraltherapyinadditiontodietaryandactivity for complications. followed underthesupervisionofaphysicianand/orregistereddietitianduetorapidweightlossandpotential weight-loss maintenance.However, thistypeofdietiscontraindicatedforcertainpopulationsandshouldonlybe Adherence toavery-low-caloriediet(<800kcalperday)resultsinsignificantweightlossandvaryingdegreesof of aweightmanagementspecialistwhoisnotalsophysicianorregistereddietitian. Any dietaryprescriptionshouldcomefromaphysicianorregistereddietitian;dietisoutsidethescope fiber foods,orhigh-fatfoods)inordertocreateacaloricdeficit Prescription ofanevidence-basedeatingplanthatrestrictscertainfood(suchashigh-carbohydratefoods,low- Prescription ofaneatingplanthatwillcreatea500–750kcal/dayor30%energydeficit adjustments madebasedonbodyweight Prescription ofa1,200–1,500kcal/dayforwomenand1,500–1,800eatingplanmen,withcalorielevel Dietary approachestoweightlossmayinclude: NUTRITION STATEMENT Low Low High Moderate Moderate High High High High High STRENGTH OFEVIDENCE 9 WEIGHT MANAGEMENT M AN OVERVIEWOFPOPULARDIETS low-carbohydrate, low-fat,andmoderatemacronutrient(balanced). and fat).Mostdietsfallintooneofthreecategoriesbasedtheironmacronutrientcomposition: advise some“ideal”proportionofintakefromthemacronutrients(i.e.,carbohydrates,protein, BEHAVIORAL STRATEGIES TOOPTIMIZENUTRITIONFORWEIGHTLOSS Table 5-5 overall fewercaloriesisincorporatedintotheregimen.Ultimately, the parameters. Likediets,theytoocancontributetoweightlossifeating advocate anyspecificcaloricrestrictionandinsteadfocusonother Paleo arebetterdescribedas“eatingplans”thandiets,theydonot Stop (DASH),Mediterranean,gluten-free,vegetarian,and specific prepackagedfoods.Some,suchastheDietaryApproachesto Others alloweverything“inmoderation,”whilestillothersrequire restrict certainfoods,whileothersfocusonaparticularmacronutrient. Within eachcategory, thediet“rules”varyconsiderably. Someheavily prevention Relapse Social support setting SMART goal Accountability training Mindfulness substitution Behavioral Stimulus control Self-monitoring Weight-loss dietsusuallyshareat leasttwokeyfeatures:theyreducecaloriesand (as wellasmanyothertheoriesnotbasedonscientificevidence,incases). any populardietstakeintoconsiderationsomeoftheprinciplesadvisedinthismodule increases thelikelihood ofmaintaininganybehavioralchange. Relapses areanormalpartofbehavior change. Helpingaclienttoanticipatebarriers,identifyproblems,anddevelop solutions programs andgroupsthatwillhelptodevelop thoserelationships.Encouragefamilyinvolvementtothehighestextent possible. who arelike-mindedandalsopracticehealthy behaviors.Ifthoserelationshipsdonotcurrentlyexist,helpdirectclients tosocial Social supportisanimportantpredictor ofweight-losssuccess.Encourageclientstostrengthenrelationshipswiththose people consider coachingtheclienttoidentify the mostrealisticopportunitiesforchange. needed toachieveagoalfeeltoodrasticfortheclient,orclienthaslowconfidence thatheorshewillbeabletoadherethem, client canincreasehisorherchancesofsuccessbypostingvisiblereminders of theweight,dietary, orfitnessgoals.Ifthechanges weight-loss successbyhelpingaclientmovefromanideaofdesiredoutcome tohavingaspecificplanforhealthierlifestyle.A SMART (specific,measurable,attainable, relevant,andtime-bound)nutritionphysical-activitygoalshelpsetthestagefor example, helptoimproveaccountability. likely toleadlastingsuccess.Having“homework”aftermeetings,emailcheck-ins, andaverbalstatementofspecificgoal,for Programs thathavebuiltinaccountability—eithertoanoutsidepersonsuchas aweight-losscoachtooneselforothers—aremore guide intakeandenjoyeatingmore,whileless. texture offood,oftentimesbyslowingdownwheneating,canhelpaclienttoreestablish internalcuesofhungerandfullnessto Helping aclienttobemoremindfulandawareofthebody’s cuesofhungerandfullnesspaymoreattentiontothetaste instead goupstairstoasittingareaandreadbook. behaviors. Forexample,someonewhotendstosnackmindlesslyonsnackswhilewatchingTVafterthekidsareputbed,might Behavioral substitutionconsistsofidentifyingproblembehaviorsandthenreplacingthosewithmorehelpfulpositive distress), clientsmightrestricteatingtothekitchenordiningroomtable. stop atavendingmachineorfast-foodrestaurant.To reducepsychologicalcuesto eat (suchasboredom,habit,stress,oremotional active andhealthyindividuals,eatsmallwell-plannedmealsthroughoutthedaytohelpavoidexcessiveeatingoranunplanned time withfriendsandcolleaguesunhelpfuleatingexercisehabitsattitudes,makeanefforttospendmorewith healthful behaviors.Forexample,aclientmightremovejunkfoodfromthepantryandstockuponfruitsvegetables,spendless Stimulus controlisalsoknownasavoidingtemptingsituationsortriggersforanunhealthfulbehaviorandseekingout weight throughdailyweighinghelpstopreventregain. is proventobehighlyeffectiveinhelpingchangebehaviorsandincreasethelikelihoodofweightloss.Additionally, self-monitoring Awareness isthefirststepofanybehaviorchange. Tracking nutritionintakeandphysicalactivity(e.g.,withfoodexerciselogs) provided inTable 5-6. described inTable 5-5.Anoverviewof20themostpopulardietsis strategies thatspecificallyrelatetomaintainingdietarychangesare changes aredescribedindepthModule4.Additionally, afewkey can beextremelychallenging.Strategiestohelpsustainbehavioral relatively straightforward,theprocessofmaintainingalifestylechange follows, aslongheorshecanstickwithit.Whilethismaysound it comestoweightloss,doesnotmattersomuchwhatdietaperson preponderance ofscientificevidencesupportsaclearconclusion:When 10 WEIGHT MANAGEMENT POPULAR DIETS—THEIRRESTRICTIONS,PROS,ANDCONS Table 5-6 THE DIET Atkins Biggest Loser Hypertension) Approaches toStop DASH (Dietary Gluten free Jenny Craig Nutrition) Relationships, Exercise, Attitudes, LEARN (Lifestyle, Low GlycemicIndex MediFast Mediterranean DESCRIPTION Calories notspecified increase carbohydrate (20g)andthengradual Induction phasewithverylow Low-carb Individual calorietargets for instructions Choose a“BiggestLoser”booktofollow Balanced Low insodium High infruitsandvegetables Calories basedonindividualneeds Developed toreducebloodpressure Balanced eatingplan Calories notspecified (wheat, grain,andbarley) Eliminates allfoodsthatcontaingluten Balanced and 2,000calories Individual calorietargetsbetween1,200 counseling orsignupforAt-Homeplan and gotoaJennyCraigcenterforweekly Purchase prepackagedmealsandsnacks Balanced Calories notspecified weight lossandhealth Emphasizes lifestylechangestopromote Balanced Calories notspecified glycemic index) Eat adietrichin“goodcarbs”(low Balanced Very lowcalories (800to1,000perday) meat andvegetablesentréeperday and Medi-fastproductsperdayplusone Five 100-caloriemealreplacementshakes Balanced Calories notspecified saturated fat;redwineinmoderation oils, andminimizesredmeat,sugar, and Emphasizes produce,nuts,andhealthful Balanced PROS Good satietyandtaste Recipes simpletoprepare Well studiedwithdemonstratedbenefit Early weightloss Encourages homecooking Exercise isakeypieceoftheprogram added sugarandsolidfats protein, andwholegrainsdiscourages Emphasizes fruits,vegetables,lean hbp_low.pdf www.nhlbi.nih.gov/files/docs/public/heart/ and mealplansavailableforfree Relatively easytofollowwithinformation Well studiedwithclearhealthbenefits who believetheyhaveglutensensitivity Treats celiacdiseaseandmayhelpthose Behavioral supportfrompeerconsultant Meals wellacceptedbymostpeople easier initially Prepackaged foodsmakeadherence Well studied Promotes lifestylechange maintenance Effective forlong-termweight-loss Self-taught weight loss,otherthanprimarilynutrition Incorporates manycriticalaspectsof processed foods Emphasizes wholefoodsandminimizes Nutritionally soundandbalanced weight loss Caloric restrictionpromotesquick Incorporates physicalactivityandexercise Clearly myriadhealthbenefits CONS High insaturatedfat fiber andfruits Nutritionally deficient,especiallyin Difficult tosustain unrealistic expectations Association withTVshowmaycreate due tolowsodiumcontent May requireretrainingoftastebuds, disease with work-upanddiagnosisofceliac Elimination ofglutencouldinterfere celiac disease Poorly studiedforthosewithout weight loss Not initselfassociatedwith professionals Peer consultantsnothealth restaurant meals Does notallowforhome-cookedand and hardtosustain Prepackaged foodsveryexpensive Initial weightlossmaycomeslowly Studies withmixedresults all foods Difficult toknowglycemicindexof powdered +waterfood) Minimal amountsof“real”food(uses Difficult tosustain have medicalsupervision Due toverylowcalorielevels,should meals May bemoreexpensivethantypical Requires planning 11 WEIGHT MANAGEMENT www.ideafit.com. Muth, N.D.(2015a).What’s thebestdietforme?IDEAFitnessJournal, March,38–45. Table 5-6,continued THE DIET Nutrisystem Ornish Paleo Pesco-vegetarian South Beach Changes (TLCDiet) Therapeutic Lifestyle Vegan Vegetarian Volumetrics Weight Watchers Zone ©2015. Reproduction withoutpermissionisstrictlyprohibited.All rightsreserved. DESCRIPTION Calorie targets1,200–1,550 supplement and shopforvegetablesfruitsto Purchase prepackagedmealsonline Balanced Calories notspecified vegetables, andwholegrains healthful, withemphasisonfruits, Foods ratedasmost(1)toleast(5) Low fat Calories notspecified fruits, andvegetables grains; emphasizesmeat,fish,poultry, No refinedsugar, diary, legumes,or gatherers did Aim toeatthewayhuntersand Low-carb Calories notspecified Include fish No meatorpoultry Balanced Calories notspecified fats; graduallyadd“healthy”carbsback moderate mono-andpolyunsaturated glycemic-index, high-protein,and Initial phaseoflow-carbfromlow Low-carb and 1,200forwomen Weight-loss caloriegoalof1,600formen Developed todecreasecholesterol Low-fat Calories notspecified No meat,fish,poultry, eggs,ordairy Balanced Calories notspecified No meat,fish,orpoultry Balanced Calories notspecified calories relativetonutrientvalue/fullness) Consume foodswithlowenergydensity(few Balanced Individualized calorietargets weight andgoals approximately 50kcal)basedoncurrent Track dailypoints(eachpoint= Balanced Individual calorietargets women and1,500caloriesformen Active weight-lossof1,200caloriesfor Balanced PROS environment Behavioral supportinonlinegroup initially Prepackaged foodsmakeadherenceeasier Emphasizes exercise Strong evidenceforcardiovascularbenefits Group sessionsforbehavioralsupport foods Discourages heavilyprocessedandrefined oily/fatty fish due tohighhealthvalueoffish,especially Inclusion offishprovidesadditionalbenefit Heart healthy Nutritionally balancedifwellplanned phase Overall healthyandbalancedafterfirst carbohydrates Differentiates healthfulandless Incorporates physicalactivity Well studied Effective atimprovingcholesterol Provides healthandenvironmentalbenefits Rich inhigh-fiberfoods Heart healthy Nutritionally balancedifwellplanned Emphasis onvegetablesandfruits Filling No foodrestrictions Well studiedwithclearefficacy Not toorestrictive Lots ofeducation Behavioral support Good varietyoffoods Effective inshortterm Recipes simpletoprepare Lower insaturatedfatthanAtkins Reprinted withpermission fromthecopyrightholder, IDEAHealth&FitnessAssociation, CONS restaurant meals Does notallowforhome-cookedand hard tosustain Prepackaged foodsexpensiveand Can beexpensive Difficult tosustain Expensive Not studied nutrient insufficiencies Restrictive, whichmayleadto May missmeat iron nutrient insufficiencies,especially If notwellplanned,mayhavesome Not wellstudied preparation Lot oftimerequiredforfood loss Encourages toomuchinitialweight Restrictive firstphase goals meet saturatedfatandcholesterol Requires readingnutritionlabelsto vitamin B12 insufficiencies, especiallyironand Very restrictive.Riskofnutrient May missmeatandfish iron nutrient insufficiencies,especially If notwellplanned,mayhavesome vegetables for peoplewhodonotlikefruitsand May behardtosustain,especially Counselors nothealthprofessionals Too costlyforsome Appeals toaspecificaudience Restricts manynutrient-densefoods allowance least partlyduetoverylowcalorie Poor long-termadherenceat

12 WEIGHT MANAGEMENT develop anadherence-enhancingactionplan,shouldtheydecidethatnowisagoodtimetomakethechange. question 1).Thisapproachismorelikelytohelptheclientgaininsightintochange,whichcanthenyoubothworkgether communication technique,withtheaimtoprovidetwothreereflectionspereachopen-endedquestion(thisisdemonstratedhere a few questionsfirst.Thefollowingareexamplesofthetypeonemightaskwhenusingmotivationalinterviewingas Therefore, whenclientsaskwhatyouthinkaboutaparticulardiet,consideraskingthemifitwouldbeokay ready tomake,butalsocanfeasiblysustain. changes fromprovidinginformationaboutwhatdietisbesttoagoalofsupportingclientmakethatheorshenotonly be helpful.Becauseadherenceisthemostimportantfactor, ratherthansomenumberoffatgramsorcarbohydratecontent,theobjective someone willloseweightandkeepitoff,providingasimpleanswertothequestion,“So,whatdoyouthinkaboutthisdiet?”isunlikely Since thereisnoone“best”dietandbecauseadherencetoaneweatingexerciseplanthemostimportantpredictorofwhether Answering theAge-oldQuestion:“So,WhatDoYou ThinkAboutThisDiet?” Health &FitnessAssociation, www.ideafit.com. ©2015.Reproductionwithoutpermission isstrictlyprohibited.Allrightsreserved. answering-the-age-old-question-ldquoso-what-do-you-think-about-this-diet. Source: FromMuth,N.D.(2015b).AnsweringtheAge-OldQuestion“So, WhatDoYou ThinkAboutThisDiet?” the clientwillbemostlikelytosustain.Fromthere—ifisready—you canhelptheclienttomakeplansoptimizeadherence. Overall, theclient’s answerstothesequestionswillhelpassess,first,ifheorsheisreadymakeachange, andifso,whatchanges weight-loss supplements?” “The eatingplanyoumentionincludesweight-losssupplements.Would itbeokwithyouifIshare youaconcernthatIhaveabout consider askingpermissiontosharetheinformation.Forexample: (for example,heorsheisconsideringtakingapotentiallydangerousweight-loss supplement),insteadofovertlycorrectinghimorher, If, duringthisseriesofquestioning,aclientprovidesinformationthatis factuallyincorrectorcouldpotentiallycausetheclientharm 6. 5. 4. 3. 2. 1. “Onascaleof1to10,beingnotatalllikely, and10beingabsolutely, howreadyareyoutomakethosechangesrightnow?” “Basedonyourresearchofthediet,whatchangesdoyouthinkyou’dneedtomakefollowthisdiet?” “Whatisitaboutthisdietthatmostappealstoyou?” “Whatdoyouknowaboutthisdietalready?” Client: Trainer: “You wanttogoonadietsoyoucanloseweight,anditquickly, butyouknowit won’tbeeasy.” quickest waytoloseweightisfollowalow-carbdiet.” Client: Trainer: least forawhile.Andthenyouloselotofweight.” Client: conversation regardingalow-carbohydratediet: After theclientanswersthisquestion,provideoneortworeflectionsofwhatyouheard.Forexample,considerpotential “So whatdoyouthinkyou’lldo?” “On thesame1to10scale,howconfidentareyouthatcansustainthesechangesforatleastnextyear?” “Yes, Ithinkso.meanitwouldbehardtomakeallofthosechanges.Butknowneedloseweight.AndI’veheardthe “Yes, right.” “Well, Iknowthatyouprettymucheliminatecarbohydrates.Nomorebread.pasta.rice.fruit,at “So youknowthatifmakesomeofthesechangestowhateat,willloseweight.”

Reprinted withpermissionfromthecopyright holder, IDEA www.ideafit.com/fitness-library/ 13 WEIGHT MANAGEMENT C CULTURAL CONSIDERATIONS cross-cultural coachingskills. al., 2012).Table 5-7outlinesseveral waysaweightmanagementspecialistcanworktodevelop experiences, andhavetheskillsneededtodeliverculturallysensitiveinterventions(Stuar-Shor et are awareoftheirownculturalvaluesandbeliefs,haveknowledgetheclient’s beliefsand cross-cultural care,expertsadvisethathealthcareproviders influences fromtheclient’s perspective. To provideeffective to theindividualwithaneffortunderstandcultural any culture.Withthissaid,interventionisbesttailored there is,ofcourse,agreatdealindividualvariationwithin Source: A STRATEGY FORDEVELOPINGCROSS-CULTURAL NUTRITIONALCOACHINGSKILLS Table 5-7 CONSIDERATION provider. Getting tochangewillrequirenegotiationamongtheclientand to change supports, previousexperiences,andaccesstoresourcessupport Current andfuturemotivationtochangeisimpactedbysocial nutrition, anddiseasepreventionimpactthechangeprocess. Cultural influenceonviewsweight,physicalactivity, healthy client-provider engagement. communication style,trust,andprejudice,impactthesuccessof characteristics oftheprovider–clientrelationship,including Provider andclientknowledge,attitudes,beliefs,traditions, Stuar-Shor, E.M.etal.(2012).Behavioralstrategiesforcardiovascular riskreductionindiverseandunderservedracial/ethnicgroups.Circulation,125,171–184. is part of a given racial, ethnic, or religious group, is partofagivenracial,ethnic,orreligiousgroup, activity behaviors.Whilethesefactorsmaypermeateintothelifeofanindividualwho ultural norms,values,beliefs,andpracticesstronglyinfluencenutritionphysical- APPLICATION her ownmotivationforchange and tobringaboutaclient’s changetalkandhelptheclientbringforthhisor reflective listening,andsummarizingtobestunderstandtheclient’s situation Practice keycommunicationskillsincludingopen-endedquestions,affirmations, making thechange Identify additionalresourcesthatmayhelpsupporttheclientinsuccessfully lose weight Determine previousexperienceoreffortstochangenutritionbehaviorsand/or access tohealthfulfoodandphysicalactivity, andhealthliteracy Assess socialsupportsandresources,includingfamilysupportforchange, Elicit client’s ownmotivations tochange nutrition, andweightloss Ask open-endedquestionstoassessunderstandingandbeliefsaroundweight, decision-making Aim tobridgedifferencesinbeliefs,communicationapproach,andapproach Be awareofbiasandprejudices Test assumptions Practice empathy the individual best tailoredto Intervention is

14 WEIGHT MANAGEMENT W physician forfurtherdiscussion. with clientsanddirecttakingorconsideringanyofthesesupplementstotheir from exhaustive.Weight managementspecialistsshouldfeelconfidentinsharingthisinformation Table 5-8highlightssomeofthemost commonlyusedweight-losssubstances,thoughthelistisfar discuss itwithhisorherphysician. and prescriptionmedications.Anyoneconsideringusingaweight-losssupplementshouldfirst can bejustasdangerouswhenusedimprudentlyorcombinedwithcertainover-the-counter products cautiouslyas,unlikemedicines,theyarenotcloselyregulatedbytheFDA.Inaddition, as claimed,consumersareadvisedtopurchaseandusethese safety andefficacy. Evenwhenusingsupplementsthatperform of supplementshaveconsistentandconvincingevidence evaluate theeffectsofsupplementsandonlyalimitednumber available toconsumers.Therearefewqualitystudies vitamins andsupplementswithweight-losspromisesare WEIGHT-LOSS SUPPLEMENTS Table 5-8 WEIGHT-LOSS SUPPLEMENTS ). Source: NationalCenterforComplementary andAlternativeMedicine( http://nccam.nih.gov/health/). Reprinted withpermissionfromMuth,N.D. (2015c). SportsNutritionforHealthProfessionals.Philadelphia:F.A. Davis. Note: OTC=Overthecounter;FDAU.S.Foodand DrugAdministration Hoodia (hCG) Human chorionicgonadotropin Green teaextract Ephedra Conjugated linoleicacid(CLA) Bitter orange prescription drugorlistat(Xenical) Alli, over-the-counter versionof PRODUCT somewhat effective, many other poorly regulated somewhat effective,manyotherpoorlyregulated approved bytheU.S.FoodandDrugAdministration(FDA),foundtobesafe hile somemedicationsareavailableonthemarketthathavebeenfullyvettedand Decreases appetite “abnormal eatingpatterns” “Resets metabolism”andchanges metabolism anddecreasesappetite Increases calorieandfat Decreases appetite Reduces bodyfatandbuildsmuscle Aids weightloss Decreases fatabsorption CLAIM Insufficient reliableevidencetorate advise inconjunctionwithpill) (which manufacturerstypically loss morethanrestrictingcalories No evidencethatitincreasesweight Insufficient reliableevidencetorate Possibly effective Possibly effectiveforweightloss health benefit Insufficient evidencetoconfirm prescription usually lessforOTCversus Effective, thoughweightloss EFFECTIVENESS supplements the effectsof studies toevaluate There arefewquality Insufficient information claims, targetofFDAinvestigation Sold illegallywithunsubstantiated Possibly safe Likely unsafeandbannedbyFDA Possibly safe with hypertension Unsafe formany, includingthose information tosayissafer Similar toephedra,andinsufficient injury FDA investigatingreportsofliver SAFETY 15 WEIGHT MANAGEMENT Medicine, Yang L.&ColditzG.A.(2015).Prevalenceof overweightandobesityintheUnited States,2007–2012.JAMAInternal Medicine, Williamson, D.F. (1993).Descriptiveepidemiologyofbodyweightandchangein U.S.adults.AnnalsofInternal U.S. DepartmentofAgriculture(2010).2010DietaryGuidelinesforAmericans. www.dietaryguidelines.gov racial/ethnic groups.Circulation,125,171–184. Stuar-Shor, E.M.etal.(2012).Behavioralstrategiesforcardiovascularriskreductionindiverse andunderserved beverage consumptionin2010.Circulation, Singh, G.M.etal.(2015).Estimatedglobal,regional,andnationaldiseaseburdens relatedtosugar-sweetened Roberts, S.B.&Dallal,G.E.(2005).Energyrequirementsandaging.PublicHealthNutrition, 8, 7A,1028–1036. Muth, N.D.(2015c).SportsNutritionforHealthProfessionals.Philadelphia:F.A. Davis. fitness-library/answering-the-age-old-question-ldquoso-what-do-you-think-about-this-diet. Muth, N.D.(2015b).AnsweringtheAge-OldQuestion“So,WhatDoYou ThinkAboutThisDiet?” Muth, N.D.(2015a).What’s thebestdietforme?IDEAFitnessJournal, March, 38–45. Enterprises Marketdata Enterprises(2013).TheU.S.Weight Loss&DietControl Market(12thed.). Preventive Medicine,26,5,302–406. Kruger, J.etal.(2004).Attemptingtoloseweight:SpecificpracticesamongU.S.adults.AmericanJournalof Society. Circulation,publishedonlineNovember12,2013. report oftheAmericanCollegeCardiology/AmericanHeartAssociationTask ForceonPracticeGuidelinesandThe Jensen, M.D.etal.(2013).2013AHA/ACC/TOSguidelinesforthemanagementofoverweightandobesityinadults:A Protein, andAminoAcids.Washington, D.C.:TheNationalAcademies Press. Institute ofMedicine(2002).DietaryReferenceIntakesforEnergy, Carbohydrate,Fiber, Fat,FattyAcids,Cholesterol, consumption withreducetheprevalenceofobesityandobesity-relateddiseases.ObesityReviews,14,8,606–619. Hu, F.B. (2013).Resolved:Thereissufficientscientificevidencethatdecreasingsugar-sweetened beverage Hall, K.D.etal.(2011).Quantificationoftheeffectenergyimbalanceonbodyweight.Lancet, 1999–2010. Flegal K.M.etal.(2012).PrevalenceofobesityandtrendsinthedistributionbodymassindexamongU.S.adults, Nutrition EducationandBehavior, 38,6Suppl.,S78–S92. Britten, P. etal.(2006).DevelopmentoffoodintakepatternsfortheMyPyramidFoodGuidanceSystem.Journal REFERENCES lasting lifestylechanges. how earlychoicesareintegratedandsustainedthrough nutritional choices.Lastingweightlossisdeterminedby Any weight-lossjourneyrequirescarefulattentionto SUMMARY Published onlineJune 22,2015:DOI:10.1001/jamainternmed.2015.2405 119, 7Pt2,646–649. New EnglandJournalofMedicine,342,12,861–867. June 29[Epubaheadofprint]. Lynbrook, N.Y.: Marketdata www.ideafit.com/ 378, 9793,826–837.