NHLBI Education Initiative

The Practical Guide Identification, Evaluation, and Treatment of and Obesity in Adults

NATIONALNATIONAL INSTITUTESINSTITUTES OFOF HEALTHHEALTH NATIONALNATIONAL ,HEART, LUNG,LUNG, ANDAND BLOODBLOOD INSTITUTEINSTITUTE NORTH AMERICAN ASSOCIATION FOR THE STUDY OF OBESITY ACKNOWLEDGMENTS: The Working Group wishes to acknowledge the additional input to the Practical Guide from the following individuals: Dr. Thomas Wadden, University of Pennsylvania; Dr. Walter Pories, East Carolina University; Dr. Steven Blair, Cooper Institute for Aerobics Research; and Dr. Van S. Hubbard, National Institute of and Digestive and Kidney . The Practical Guide Identification, Evaluation, and Treatment of Overweight and Obesity in Adults

National Institutes of NHLBI Obesity Education Initiative

National Heart, Lung, and Blood Institute North American Association for the Study of Obesity

NIH Publication Number 00-4084 October 2000 NHLBI Obesity Education Initiative Barbara C. Hansen, Ph.D. David F. Williamson, Ph.D., M.S. Expert Panel on the Identification, University of School of Centers for Control and Prevention Evaluation, and Treatment of Millicent Higgins, M.D. G. Terence Wilson, Ph.D. Overweight and Obesity in Adults. University of Michigan Rutgers Eating Disorders Clinic F.Xavier Pi-Sunyer, M.D., M.P.H. James O. Hill, Ph.D. College University of Colorado EX-OFFICIO MEMBERS of Physicians and Surgeons Health Sciences Center Clarice D. Brown, M.S. Chair of the Panel Barbara V. Howard, Ph.D. Coda Research Inc. Medlantic Research Institute Karen A. Donato, M.S., R.D.* MEMBERS Robert J. Kuczmarski, Dr.P.H., R.D. Executive Director of the Panel Coordinator, NHLBI Obesity Diane M. Becker, Sc.D., M.P.H. National Center for Health Statistics Education Initiative The Centers for Disease Control and Prevention National Heart, Lung, and Blood Institute Claude Bouchard, Ph.D. , Ph.D., R.D., M.P.H. National Institutes of Health Laval University The University of Pennsylvania Nancy Ernst, Ph.D., R.D.* Richard A. Carleton, M.D. R. Dee Legako, M.D. National Heart, Lung, and Blood Institute Brown University School of Medicine Prime Care Canyon Park Family Physicians, Inc. National Institutes of Health Graham A. Colditz, M.D., Dr.P.H. D. Robin Hill, Ph.D.* Harvard Medical School T. Elaine Prewitt, Dr.P.H., R.D. Loyola University Medical Center National Heart, Lung, and Blood Institute William H. Dietz, M.D., Ph.D. National Institutes of Health National Center for Chronic Disease Albert P. Rocchini, M.D. Michael J. Horan, M.D., Sc.M.* Prevention and Health Promotion University of Michigan Medical Center National Heart, Lung, and Blood Institute Centers for Disease Control and Prevention Philip L Smith, M.D. National Institutes of Health John P. Foreyt, Ph.D. The Johns Hopkins Van S. Hubbard, M.D., Ph.D. Baylor College of Medicine and Allergy Center National Institute of Diabetes and Linda G. Snetselaar, Ph.D., R.D. Robert J. Garrison, Ph.D. Digestive and Kidney Diseases University of , Memphis University of Iowa James P. Kiley, Ph.D.* James R. Sowers, M.D. Scott M. Grundy, M.D., Ph.D. National Heart, Lung, and Blood Institute Wayne State University School of Medicine University of Texas Southwestern National Institutes of Health Medical Center at Dallas University Health Center Eva Obarzanek, Ph.D., R.D., M.P.H.* Michael Weintraub, M.D. National Heart, Lung, and Blood Institute and Drug Administration National Institutes of Health North American Association for the Susan Fried, Ph.D. *NHLBI Obesity Initiative Task Force Member Study of Obesity Practical Guide Rutgers University CONSULTANT Development Committee Patrick Mahlen O'Neil, Ph.D. Medical University of South Carolina David Schriger, M.D., M.P.H., F.A.C.E.P. Louis J. Aronne, M.D., F.A.C.P. University of California Henry Buchwald, M.D. , Chair Los Angeles School of Medicine University of Minnesota MEMBERS George Cowan, M.D. SAN ANTONIO COCHRANE CENTER University of Tennessee Charles Billington, M.D. Elaine Chiquette, Pharm.D. College of Medicine University of Minnesota Robert Brolin, M.D. Cynthia Mulrow, M.D., M.Sc. George Blackburn, M.D., Ph.D. UMDNJ-Robert Wood Johnson V.A. Cochrane Center at San Antonio Harvard University Medical School Audie L. Murphy Memorial Karen A. Donato, M.S., R. D. Veterans Hospital NHLBI Obesity Education Initiative EX-OFFICIO MEMBERS STAFF National Heart, Lung, and James O. Hill, Ph.D. Blood Institute University of Colorado Adrienne Blount, Maureen Harris, M.S., R.D., National Institutes of Health Health Sciences Center Anna Hodgson, M.A., Pat Moriarty, M.Ed., R.D., R.O.W. Sciences, Inc. Arthur Frank, M.D. Edward Bernstein, M.P.H. George Washington University North American Association for the Study of Obesity Table of Contents

Foreword ...... v

How To Use This Guide...... vi

Executive Summary ...... 1 Assessment ...... 1 ...... 1 Circumference ...... 1 Risk Factors or Comorbidities...... 1 Readiness To Lose Weight...... 2 Management...... 2 ...... 2 Prevention of ...... 2 Therapies...... 2 Dietary Therapy...... 2 ...... 3 Behavior Therapy ...... 3 Pharmacotherapy...... 3 Weight Loss ...... 4 Special Situations...... 4

Introduction...... 5 The Problem of Overweight and Obesity ...... 5

Treatment Guidelines...... 7 Assessment and Classification of Overweight and Obesity...... 8 Assessment of Risk Status ...... 11 Evaluation and Treatment Strategy ...... 15 Ready or Not: Predicting Weight Loss ...... 21 Management of Overweight and Obesity...... 23

Weight Management Techniques ...... 25 Dietary Therapy ...... 26 Physical Activity...... 28 Behavior Therapy ...... 30 Making the Most of the Patient Visit...... 30 Pharmacotherapy ...... 35 Weight Loss Surgery...... 38

Weight Reduction After Age 65 ...... 41

References ...... 42

iii Introduction to the Appendices ...... 45 Appendix A. Body Mass Index Table...... 46 Appendix B. Shopping—What to Look For ...... 47 Appendix C. Low Calorie, Lower Alternatives...... 49 Appendix D. Sample Reduced Calorie Menus...... 51 Appendix E. Food Exchange List...... 57 Appendix F. Food Preparation—What to Do ...... 59 Appendix G. Dining Out—How To Choose...... 60 Appendix H. Guide to Physical Activity ...... 62 Appendix I. Guide to Behavior Change ...... 68 Appendix J. Weight and Goal Record ...... 71 Appendix K. Weekly Food and Activity Diary...... 74 Appendix L. Additional Resources...... 75

List of Tables Table 1. Classifications for BMI ...... 1 Table 2. Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Risk...... 10 Table 3. A Guide to Selecting Treatment...... 25 Table 4. Low-Calorie Step I ...... 27 Table 5. Examples of Moderate Amounts of Physical Activity ...... 29 Table 6. Weight Loss Drugs ...... 36

List of Figures Figure 1. Age-Adjusted Prevalence of Overweight (BMI 25–29.9) and Obesity (BMI ≥ 30) ...... 6 Figure 2. NHANES III Age-Adjusted Prevalence of High Blood Pressure (HBP), High Total Blood (TBC), and Low-HDL by Two BMI Categories ..6 Figure 3. Measuring-Tape Position for Waist (Abdominal) Circumference in Adults ...... 9 Figure 4. Treatment Algorithm ...... 16 Figure 5. Surgical Procedures in Current Use...... 38

iv Foreword

n June 1998, the Clinical Guidelines on the The Guide was prepared by a working group con- Identification, Evaluation, and Treatment of vened by the North American Association for the Overweight and Obesity in Adults: Evidence Study of Obesity and the National Heart, Lung, and Report was released by the National Heart, Lung, Blood Institute. Three members of the American and Blood Institute’s (NHLBI) Obesity Education Society for also participated in IInitiative in cooperation with the National Institute the working group. Members of the Expert Panel, of Diabetes and Digestive and Kidney Diseases especially the Panel Chairman, assisted in the review (NIDDK). The impetus behind the clinical practice and development of the final product. Special thanks guidelines was the increasing prevalence of over- are also due to the 50 representatives of the various weight and obesity in the United States and the need disciplines in primary care and others who reviewed to alert practitioners to accompanying health risks. the preprint of the document and provided the working group with excellent feedback. The Expert Panel that developed the guidelines consisted of 24 experts, 8 ex-officio members, and a The Practical Guide will be distributed to primary consultant methodologist representing the fields of care physicians, nurses, registered , and primary care, clinical , physiology, nutritionists as well as to other interested , physiology, and pulmonary disease. practitioners. It is our hope that the tools provided here The guidelines were endorsed by representatives help to complement the skills needed to effectively of the Coordinating Committees of the National manage the millions of overweight and obese individ- Cholesterol Education Program and the National uals who are attempting to manage their weight. High Blood Pressure Education Program, the North American Association for the Study of Obesity, and the NIDDK National Task Force on the Prevention and Treatment of Obesity.

This Practical Guide to the Identification, Evaluation, David York, Ph.D. Claude Lenfant,M.D. and Treatment of Overweight and Obesity in Adults is President Director largely based on the evidence report prepared by the North American Association National Heart, Lung, Expert Panel and describes how health care practition- for the Study of Obesity and Blood Institute ers can provide their patients with the direction and National Institutes support needed to effectively lose weight and keep it of Health off. It provides the basic tools needed to appropriately assess and manage overweight and obesity. The guide includes practical information on dietary therapy, physical activity, and behavior therapy, while also providing guidance on the appropriate use of pharmacotherapy and surgery as treatment options.

v How to Use This Guide

verweight and obesity, serious and growing health problems, are not receiving the attention they deserve from primary care practitioners. Among the reasons cited for not treating overweight and obesity is the lack of authoritative information to guide treatment. This Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults was developed cooperatively by Othe North American Association for the Study of Obesity (NAASO) and the National Heart, Lung, and Blood Institute (NHLBI). It is based on the Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: Evidence Report developed by the NHLBI Expert Panel and released in June 1998. The Expert Panel used an evidence-based methodology to develop key recommendations for assessing and treating overweight and obese patients. The goal of the Practical Guide is to provide you with the tools you need to effectively manage your overweight and obese adult patients in an efficient manner.

The Guide has been developed to help you easily access all of the information you need.

The Executive Summary contains the essential information in an abbreviated form.

The Treatment Guidelines section offers details on assessment and management of patients and features the Expert Panel’s Treatment Algorithm, which provides a step-by-step approach to learning how to manage patients.

The Appendix contains practical tools related to diet, physical activity, and behavioral modification needed to educate and inform your patients. The Appendix has been formatted so that you can copy it and explain it to your patients.

Managing overweight and obese patients requires a variety of skills. Physicians a key role in evaluating and treating such patients. Also important are the special skills of nutritionists, registered dietitians, psychologists, and exercise physiologists. Each health care practitioner can help patients learn to make some of the changes they may need to make over the long term. Organizing a “team” of various health care practitioners is one way of meeting the needs of patients. If that approach is not possible, patients can be referred to other specialists required for their care.

To get started, just follow the Ten Step approach.

vi Ten Steps to Treating Overweight and Obesity in the Primary Care Setting

Measure height and weight so that you can the patient can stick with the 1,600 kcal/day estimate your patient’s BMI from the table diet but does not lose weight you may want to 1 in Appendix A. try the 1,200 kcal/day diet. If a patient on either diet is hungry, you may want to increase the calories by 100 to 200 per day. Measure waist circumference Included in Appendix D are samples of both 2 as described on page 9. a 1,200 and 1,600 calorie diet. Assess comorbidities as described on Discuss a physical activity goal with the pages 11–12 in the section on patient using the Guide to Physical Activity 3 “Assessment of Risk Status.” 7 (see Appendix H). Emphasize the importance of physical activity for weight maintenance and risk reduction. Should your patient be treated? Take the information you have gathered above and use 4 Figure 4, the Treatment Algorithm, on pages Review the Weekly Food and Activity 16–17 to decide. Pay particular attention to Diary (see Appendix K) with the patient. Box 7 and the accompanying explanatory 8 Remind the patient that record-keeping has text. If the answer is “yes” to treatment, been shown to be one of the most successful decide which treatment is best using Table 3 behavioral techniques for weight loss and on page 25. maintenance. Write down the diet, physical activity, and behavioral goals you have agreed on at the bottom. Is the patient ready and motivated to lose weight? Evaluation of readiness should 5 include the following: (1) reasons and Give the patient copies of the dietary motivation for weight loss, (2) previous information (see Appendices B–G), attempts at weight loss, (3) support expected 9 the Guide to Physical Activity (see from family and friends, (4) understanding of Appendix H), the Guide to Behavior risks and benefits, (5) attitudes toward Change (see Appendix I), and the Weekly physical activity, (6) time availability, Food and Activity Diary (see Appendix K). and (7) potential barriers to the patient’s adoption of change. Enter the patient’s information and the goals you have agreed on in the Weight and Which diet should you recommend? 10 Goal Record (see Appendix J). It is important In general, diets containing 1,000 to 1,200 to keep track of the goals you have set and 6 kcal/day should be selected for most women; to ask the patient about them at the next visit a diet between 1,200 kcal/day and 1,600 to maximize compliance. Have the patient kcal/day should be chosen for men and may schedule an appointment to see you or your be appropriate for women who weigh 165 staff for followup in 2 to 4 weeks. pounds or more, or who exercise regularly. If

vii

Executive Summary

Successful treatment … weight alone. Neither bioelectric patients who are categorized as nor- A lifelong effort. impedance nor height-weight tables mal or overweight. It is not neces- provide an advantage over BMI sary to measure waist circumference Treatment of an overweight or in the clinical management of in individuals with BMIs ≥ 35 kg/m2 obese person incorporates a two- all adult patients, regardless of since it adds little to the predictive step process: assessment and gender. Clinical judgment must be power of the disease risk classifica- management. Assessment includes employed when evaluating very tion of BMI. Men who have waist determination of the degree of muscular patients because BMI may circumferences greater than 40 inch- obesity and overall health status. overestimate the degree of fatness in es, and women who have waist cir- Management involves not only these patients. The recommended cumferences greater than 35 inches, weight loss and maintenance of classifications for BMI, adopted are at higher risk of diabetes, dys- body weight but also measures to by the Expert Panel on the lipidemia, , and cardio- control other risk factors. Obesity Identification, Evaluation, and vascular disease because of excess is a chronic disease; patient and Treatment of Overweight and abdominal fat. Individuals with practitioner must understand that Obesity in Adults and endorsed by waist circumferences greater than successful treatment requires a leading organizations of health these values should be considered lifelong effort. Convincing evidence professionals, are shown in Table 1. one risk category above that defined supports the benefit of weight loss for reducing blood pressure, Table 1 lowering blood glucose, and Classifications for BMI improving . BMI <18.5 kg/m2 Normal weight 18.5–24.9 kg/m2 Assessment Overweight 25–29.9 kg/m2 Obesity (Class 1) 30–34.9 kg/m2 Body Mass Index Obesity (Class 2) 35–39.9 kg/m2 Assessment of a patient should Extreme obesity (Class 3) ≥40 kg/m2 include the evaluation of body mass index (BMI), waist circumference, and overall medical risk. To esti- Waist Circumference by their BMI. The relationship mate BMI, multiply the individual’s Excess abdominal fat is an impor- between BMI and waist circumfer- weight (in pounds) by 703, then tant, independent risk factor for dis- ence for defining risk is shown in divide by the height (in inches) ease. The evaluation of waist cir- Table 2 on page 10. squared. This approximates BMI cumference to assess the risks asso- in kilograms per meter squared ciated with obesity or overweight is Risk Factors or Comorbidities (kg/m2). There is evidence to sup- supported by research. The measure- Overall risk must take into account port the use of BMI in risk assess- ment of waist-to-hip ratio provides the potential presence of other risk ment since it provides a more accu- no advantage over waist circumfer- factors. Some diseases or risk rate measure of total body fat com- ence alone. Waist circumference factors associated with obesity place pared with the assessment of body measurement is particularly useful in patients at a high absolute risk for

1 subsequent mortality; these will Support expected from family py, the priority should be weight require aggressive management. and friends maintenance achieved through com- Other conditions associated with Understanding of risks bined changes in diet, physical activi- obesity are less lethal but still and benefits ty, and behavior. Further weight loss require treatment. Attitudes toward physical can be considered after a period of activity weight maintenance. Those diseases or conditions that Time availability denote high absolute risk are Potential barriers, including Prevention of Weight Gain established coronary heart disease, financial limitations, to the In some patients, weight loss or other atherosclerotic diseases, patient’s adoption of change a reduction in body fat is not , and apnea. achievable. A goal for these , , patients should be the prevention incontinence, and gynecological Management of further weight gain. Prevention abnormalities such as amenorrhea of weight gain is also an appropri- and menorrhagia increase risk but Weight Loss ate goal for people with a BMI are not generally life-threatening. Individuals at lesser risk should be of 25 to 29.9 who are not other- Three or more of the following counseled about effective lifestyle wise at high risk. risk factors also confer high changes to prevent any further absolute risk: hypertension, ciga- rette , high low-density Weight loss therapy is Therapies lipoprotein cholesterol, low recommended for patients high-density lipoprotein choles- A combination of diet modification, terol, impaired glucose, with a BMI ≥ 30 and for patients increased physical activity, and family history of early cardiovas- with a BMI between 25 and 29.9 behavior therapy can be effective. cular disease, and age (male ≥ 45 OR a high-risk waist years, female ≥ 55 years). The circumference, and two Dietary Therapy or more risk factors. integrated approach to assessment Caloric intake should be reduced and management is portrayed in by 500 to 1,000 calories per day Figure 4 on pages 16–17 weight gain. Goals of therapy are to (kcal/day) from the current level. (Treatment Algorithm). reduce body weight and maintain a Most overweight and obese people lower body weight for the long should adopt long-term nutritional Readiness To Lose Weight term; the prevention of further adjustments to reduce caloric intake. The decision to attempt weight-loss weight gain is the minimum goal. Dietary therapy includes instructions treatment should also consider the An initial weight loss of 10 percent for modifying diets to achieve this patient’s readiness to make the nec- of body weight achieved over 6 goal. Moderate caloric reduction essary lifestyle changes. Evaluation months is a recommended target. is the goal for the majority of cases; of readiness should include the The rate of weight loss should be 1 however, diets with greater caloric following: to 2 pounds each week. Greater deficits are used during active Reasons and motivation rates of weight loss do not achieve weight loss. The diet should be low for weight loss better long-term results. After the in calories, but it should not be too Previous attempts at weight loss first 6 months of weight loss thera- low (less than 800 kcal/day). Diets

2 diture and plays an integral role in ing, stress management, stimulus Reductions of 500 weight maintenance. Physical activ- control, problem-solving, contin- to 1,000 kcal/day ity also reduces the risk of heart gency management, cognitive will produce a recom- disease more than that achieved by restructuring, and social support. mended weight loss of weight loss alone. In addition, Behavioral therapies may be 1 to 2 pounds per week. increased physical activity may help employed to promote adoption of reduce body fat and prevent the diet and activity adjustments; these lower than 800 kcal/day have been decrease in muscle mass often will be useful for a combined found to be no more effective than found during weight loss. For the approach to therapy. Strong evi- low-calorie diets in producing obese patient, activity should gener- dence supports the recommendation weight loss. They should not be ally be increased slowly, with care that weight loss and weight mainte- used routinely, especially not by taken to avoid injury. A wide vari- nance programs should employ a providers untrained in their use. ety of activities and/or household combination of low-calorie diets, In general, diets containing chores, including , dancing, increased physical activity, and 1,000 to 1,200 kcal/day should be gardening, and team or individual behavior therapy. selected for most women; a diet sports, may help satisfy this goal. between 1,200 kcal/day and 1,600 All adults should set a long-term Pharmacotherapy kcal/day should be chosen for goal to accumulate at least 30 min- Pharmacotherapy may be helpful men and may be appropriate for utes or more of moderate-intensity for eligible high-risk patients. women who weigh 165 pounds physical activity on most, and Pharmacotherapy, approved by the or more, or who exercise. preferably all, days of the week. FDA for long-term treatment, can Long-term changes in food choices be a helpful adjunct for the treat- are more likely to be successful Behavior Therapy ment of obesity in some patients. when the patient’s preferences are Including behavioral therapy These drugs should be used only in taken into account and when the helps with compliance. the context of a treatment program patient is educated about food com- Behavior therapy is a useful adjunct that includes the elements described position, labeling, preparation, and to planned adjustments in food previously—diet, physical activity portion size. Although dietary fat is intake and physical activity. changes, and behavior therapy. a rich source of calories, reducing Specific behavioral strategies If lifestyle changes do not promote dietary fat without reducing calories include the following: self-monitor- weight loss after 6 months, drugs will not produce weight loss. Frequent contact with practitioners during the period of diet adjustment is likely to improve compliance.

Physical Activity 1,000 to 1,200 kcal/day Physical activity has direct for most women and indirect benefits. Increased physical activity is 1,200 to 1,600 kcal/day important in efforts to lose weight should be chosen for men because it increases energy expen-

3 and serious comorbid conditions. Effective Therapies (The term “clinically severe A combination of diet modification, obesity” is preferred to the once increased physical activity, and commonly used term “morbid behavior therapy can be effective. obesity.”) Surgical patients should be monitored for complications and lifestyle adjustments throughout their lives. should be considered. Pharmaco- therapy is currently limited to those patients who have a BMI ≥ 30, or Special Situations those who have a BMI ≥ 27 if con- comitant obesity-related risk factors Involve other health or diseases exist. However, not all professionals when possible, patients respond to a given drug. especially for special situations. If a patient has not lost 4.4 pounds Although research regarding (2 kg) after 4 weeks, it is not likely absorption of fat-soluble obesity treatment in older people that this patient will benefit from and . The decision to add a is not abundant, age should not the drug. Currently, and drug to an obesity treatment pro- preclude therapy for obesity. In are approved by the FDA gram should be made after consid- people who smoke, the risk of for long-term use in weight loss. eration of all potential risks and weight gain is often a barrier to Sibutramine is an suppres- benefits and only after all behav- . In these sant that is proposed to work via ioral options have been exhausted. patients, cessation of smoking norepinephrine and serotonergic should be encouraged first, and mechanisms in the brain. Orlistat Weight Loss Surgery weight loss therapy should be inhibits fat absorption from the Surgery is an option for patients an additional goal. intestine. Both of these drugs have with extreme obesity. side effects. Sibutramine may Weight loss surgery provides A weight loss and maintenance increase blood pressure and induce medically significant sustained program can be conducted by a tachycardia; orlistat may reduce the weight loss for more than 5 years practitioner without specialization in most patients. Although there in weight loss so long as that are risks associated with surgery, person has the requisite interest clinically severe obesity it is not yet known whether these and knowledge. However, a (BMI ≥ 40) or a BMI ≥ 35 risks are greater in the long term variety of practitioners with and serious comorbid than those of any other form of special skills are available and conditions may warrant treatment. Surgery is an option may be enlisted to assist in the surgery for weight loss. for well-informed and motivated development of a program. patients who have clinically severe obesity (BMI ≥ 40) or a BMI ≥ 35

4 Introduction

besity is a complex, and should engage the assistance of of preventable in the United 15 multifactorial disease other professionals. This guide pro- States today, overweight and obesity that develops from vides the basic tools needed to pose a major challenge. the interaction assess and manage overweight and between genotype obesity for a variety of health profes- Oand the environment. Our under- sionals, including nutritionists, regis- According to the Expert Panel, overweight is defined as a body standing of how and why obesity tered dietitians, exercise physiolo- mass index (BMI) of 25 to occurs is incomplete; however, it gists, nurses, and psychologists. 29.9 kg/m2, and obesity is involves the integration of social, These professionals offer expertise defined as a BMI ≥ 30 kg/m2. behavioral, cultural, physiological, in dietary , physical activ- metabolic, and genetic factors.1 ity, and behavior changes and can be used for assessment, treatment, and However, overweight and obesity are Today, health care practitioners are followup during weight loss and not mutually exclusive, since obese encouraged to play a greater role in weight maintenance. The relation- persons are also overweight. A BMI the . Many ship between the practitioner and of 30 indicates an individual is about physicians are seeking guidance in these professionals can be a direct, 30 pounds overweight; it may be effective methods of treatment. formal one (as a “team”), or it may exemplified by a 221-pound person This guide provides the basic tools be based on an indirect referral. A who is 6 feet tall or a 186-pound indi- needed to assess and manage over- positive, supportive attitude and vidual who is 5 feet 6 inches tall. The weight and obesity in an office set- encouragement from all profession- number of overweight and obese men ting. A physician who is familiar als are crucial to the continuing suc- and women has risen since 1960 with the basic elements of these ser- cess of the patient. (Figure 1); in the last decade, the per- vices can more successfully fulfill centage of adults, ages 20 years or the critical role of helping the The Problem of older, who are in these categories has patient improve health by identify- Overweight and Obesity increased to 54.9 percent.2 Over- ing the problem and coordinating An estimated 97 million adults in the weight and obesity are especially evi- other resources within the commu- United States are overweight or dent in some minority groups, as nity to assist the patient. obese.2 These conditions substantial- well as in those with lower incomes ly increase the risk of morbidity and less education.16,17 Effective management of overweight from hypertension,3 ,4 and obesity can be delivered by a type 2 diabetes,5,6,7,8 coronary artery The presence of overweight and obe- variety of health care professionals disease,9 ,10 dis- sity in a patient is of medical con- with diverse skills working as a ease,11 osteoarthritis,12 and sleep cern for several reasons. It increases team. For example, physician apnea and respiratory problems,13 as the risk for several diseases, particu- involvement is needed for the initial well as of the endometrium, larly cardiovascular diseases (CVD) 7,8 assessment of risk and the prescrip- breast, prostate, and colon.14 Higher and diabetes mellitus. Data from tion of appropriate treatment pro- body weights are also associated NHANES III show that morbidity grams that may include pharma- with an increase in mortality from for a number of health conditions cotherapy, surgery, and the medical all causes.5 Obese individuals may increases as BMI increases in both management of the comorbidities of also suffer from social stigmatization men and women (Figure 2). obesity. In addition, physicians can and discrimination. As a major cause

5 Figure 1 Age-Adjusted Prevalence of Overweight (BMI 25–29.9) and Obesity (BMI ≥ 30)

50

41.1 39.1 39.4

40 37.8

30

24.3 24.7 24.9 23.6 23.6

19.9 Percent 20 16.1 16.3 15.1

12.2 11.3 10.4 10

NHES I (1960-62) 0 NHANES I (1971-74) Men Women Men Women NHANES II (1976-80) (BMI 25–29.9) (BMI ≥ 30) NHANES III (1988-94) Source: CDC/NCHS. United States. 1960-94, Ages 20-74 years. For comparison across surveys, data for subjects ages 20 to 74 years were age-adjusted by the direct method to the total U.S. population for 1980, using the age-adjusted categories 20-29y, 30-39y, 40-49y, 50-59y, 60-69y, and 70-79y.

Figure 2

NHANES III Age-Adjusted Prevalence of High Blood Pressure (HBP),* High Total Blood Cholesterol (TBC),† and Low-HDL‡ by Two BMI Categories

HBP TBC HDL

45 42.0 39.2 40

35 32.4 31.5 30 24.3 25 20.2 20 18.3 16.2 16.3

Prevalence 14.7 14.6 15

10 9.3

5

0 ≥ ≥ ≥ Men <25 30 <25 30 <25 30 Women BMI

* Defined as mean systolic blood pressure > 140 mm Hg, mean diastolic blood pressure > 90 mm Hg, or currently taking antihypertensive . † Defined as > 240 mg/dl. ‡ Defined as < 35 mg/dl in men and < 45 mg/dl in women.

Source: Brown C et al. Body mass index and the prevalence of hypertension and dyslipidemia (in press).

6 Treatment Guidelines

lthough there is agreement about the health risks of overweight and obesity, there is less agreement about Tailor Treatment to the their management. Some have argued against treating Needs of the Patient obesity because of the difficulty in maintaining long-term weight loss, and because of the potentially Standard treatment approaches for overweight and obesity must Anegative consequences of weight , a pattern frequently seen be tailored to the needs of various in obese individuals. Others argue that the potential hazards of patients or patient groups. Large treatment do not outweigh the known hazards of being obese. individual variation exists within The treatment guidelines provided are based on the most thorough any social or cultural group; fur- examination of the scientific evidence reported to date on the thermore, substantial overlap effectiveness of various treatment strategies available for weight loss occurs among subcultures within and weight maintenance. the larger society. There is, there- fore, no “cookbook” or standard- Treatment of the overweight and obese patient is a two-step process: ized set of rules to optimize weight assessment and management. reduction with a given type of patient. However, obesity treatment Assessment requires determination of the degree of obesity programs that are culturally and the absolute risk status. sensitive and incorporate a patient’s characteristics must do Management includes the reduction of excess weight and the following: maintenance of this lower body weight, as well as the institution of additional measures to control any associated risk factors. Adapt the setting and staffing for the program. The aim of this guide is to provide useful advice on how to Understand how the obesity achieve weight reduction and how to maintain a lower body weight. treatment program integrates Obesity is a chronic disease; the patient and the practitioner need into other aspects of the patient’s to understand that successful treatment requires a lifelong effort. health care and self-care.

Expect and allow modifications to a program based on a patient’s response and preferences.

7 Assessment and Classification of Overweight and Obesity

You can calculate BMI as follows lthough accurate methods to before and during weight loss treat-

weight (kg) assess body fat exist, the ment (Figure 3). Computed tomog- BMI = measurement of body fat by raphy19 and magnetic resonance height squared (m2) A these techniques is expensive and is imaging20 are both more accurate often not readily available to most but are impractical for routine clini- If pounds and inches are used clinicians. Two surrogate measures cal use. Fat located in the abdomi- are important to assess body fat: nal region is associated with a weight (pounds) x 703 BMI = Body mass index (BMI) greater health risk than peripheral height squared (inches2) Waist circumference fat (i.e., fat in the gluteal-femoral A BMI chart is provided in Appendix A. region). Furthermore, abdominal fat BMI is recommended as a practical appears to be an independent risk Calculation Directions and Sample approach for assessing body fat in predictor when BMI is not marked- Here is a shortcut method for calculating the clinical setting. It provides a ly increased.21,22 Therefore, waist or BMI. (Example: for a person who is 5 feet 5 inches tall weighing 180 lbs.) more accurate measure of total abdominal circumference and BMI body fat compared with the assess- should be measured not only for the 1. Multiply weight (in pounds) by 703 ment of body weight alone.18 initial assessment of obesity but 180 x703 =126,540 The typical body weight tables are also for monitoring the efficacy based on mortality outcomes, and of the weight loss treatment for 2. Multiply height (in inches) by height (in inches) they do not necessarily predict mor- patients with a BMI < 35. 65 x 65 =4,225 bidity. However, BMI has some limitations. For example, BMI over- The primary classification of over- 3. Divide the answer in step 1 by the answer in step 2 to get the BMI. estimates body fat in persons who weight and obesity is based on the are very muscular, and it can under- assessment of BMI. This classifica- 126,540/4,225 = 29.9 estimate body fat in persons who tion, shown in Table 2, relates BMI BMI = 29.9 have lost muscle mass (e.g., many to the risk of disease. It should be elderly). BMI is a direct calculation noted that the relationship between based on height and weight, regard- BMI and disease risk varies among High-Risk Waist less of gender. individuals and among different Circumference populations. Some individuals with Men: > 40 in (> 102 cm) Waist circumference is the most mild obesity may have multiple risk Women: > 35 in (> 88 cm) practical tool a clinician can use to factors; others with more severe evaluate a patient’s abdominal fat obesity may have fewer risk factors.

Disease Risks

A high waist circumference is associat- ed with an increased risk for type 2 diabetes, dyslipidemia, hypertension, and CVD in patients with a BMI between 25 and 34.9 kg/m2.

8 Figure 3 Waist Circumference Measurement Clinical judgment must be To measure waist used in interpreting BMI circumference, locate in situations that may affect its the upper hip bone and accuracy as an indicator of total the top of the right iliac body fat. Examples of these crest. Place a measur- situations include the presence ing tape in a horizontal of edema, high muscularity, muscle plane around the abdo- , and individuals who are men at the level of the limited in stature. The relationship iliac crest. Before read- between BMI and body fat content ing the tape measure, varies somewhat with age, gender, ensure that the tape is and possibly ethnicity because of snug, but does not differences in the composition of compress the skin, and lean tissue, height, and is parallel to the floor. hydration state.23,24 For example, The measurement is older persons often have lost made at the end of a muscle mass; thus, they have normal expiration. more fat for a given BMI than younger persons. Women may Measuring-Tape Position for Waist have more body fat for a given (Abdominal) Circumference in Adults BMI than men, whereas patients with clinical edema may have less fat for a given BMI compared with It should be noted that the risk lev- ence measurement is particularly those without edema. Nevertheless, els for disease depicted in Table 2 useful in patients who are catego- these circumstances do not are relative risks; in other words, rized as normal or overweight in markedly influence the validity of they are relative to the risk at terms of BMI. For individuals with BMI for classifying individuals into normal body weight. There are no a BMI ≥ 35, waist circumference broad categories of overweight randomized, controlled trials that adds little to the predictive power and obesity in order to monitor support a specific classification sys- of the disease risk classification of the weight status of individuals tem to establish the degree of dis- BMI. A high waist circumference is in clinical settings.23 ease risk for patients during weight associated with an increased risk for loss or weight maintenance. type 2 diabetes, dyslipidemia, cumference over time may be help- hypertension, and CVD in ful; it can provide an estimate of Although waist circumference and patients with a BMI between increases or decreases in abdominal BMI are interrelated, waist circum- 25 and 34.9 kg/m.2,25 fat, even in the absence of changes ference provides an independent in BMI. Furthermore, in obese prediction of risk over and above In addition to measuring BMI, patients with metabolic complica- that of BMI. The waist circumfer- monitoring changes in waist cir- tions, changes in waist circumfer-

9 Table 2 Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Risk*

Disease Risk* BMI Obesity Class (Relative to Normal Weight (kg/m2) and Waist Circumference)

Men ≤40 in (≤ 102 cm) > 40 in (> 102 cm) Women ≤ 35 in (≤ 88 cm) > 35 in (> 88 cm)

Underweight < 18.5 - - Normal† 18.5–24.9 - - Overweight 25.0–29.9 Increased High Obesity 30.0–34.9 I High Very High 35.0–39.9 II Very High Very High Extreme Obesity ≥ 40 III Extremely High Extremely High

* Disease risk for type 2 diabetes, hypertension, and CVD. † Increased waist circumference can also be a marker for increased risk even in persons of normal weight. Adapted from “Preventing and Managing the Global Epidemic of Obesity. Report of the World Health Organization Consultation of Obesity.” WHO, Geneva, June 1997.26

ence are useful predictors of gate for abdominal fat.23 In some changes in populations (e.g., Asian Americans (CVD) risk factors.27 Men are at or persons of Asian descent), waist increased relative risk if they have circumference is a better indicator a waist circumference greater than of relative disease risk than BMI.28 40 inches (102 cm); women are at For older individuals, waist circum- an increased relative risk if they ference assumes greater value for have a waist circumference greater estimating risk of obesity-related than 35 inches (88 cm). diseases. Table 2 incorporates both BMI and waist circumference in There are ethnic and age-related the classification of overweight and differences in body fat distribution obesity and provides an indication that modify the predictive validity of relative disease risk. of waist circumference as a surro-

10 Assessment of Risk Status

ssessment of the patient’s risk according to BMI and waist arterial disease, abdominal aortic status includes the determina- circumference. They relate to , or symptomatic carotid Ation of the following: the the need to institute weight loss artery disease. degree of overweight or obesity therapy, but they do not define Type 2 diabetes (fasting plasma using BMI, the presence of abdomi- the required intensity of risk glucose ≥ 126 mg/dL or 2-h nal obesity using waist circumfer- factor modification. The latter postprandial plasma glucose ence, and the presence of concomi- is determined by the estimation ≥ 200 mg/dL) is a major risk fac- tant CVD risk factors or comorbidi- of absolute risk based on the tor for CVD. Its presence alone ties. Some obesity-associated dis- presence of associated disease places a patient in the category eases and risk factors place patients or risk factors. of very high absolute risk. in a very high-risk category for sub- . Symptoms and sequent mortality. Patients with these 2. Identify patients at very high signs include very loud diseases will require aggressive mod- absolute risk. Patients with the or cessation of breathing during ification of risk factors in addition to following diseases have a very sleep, which is often followed the clinical management of the dis- high absolute risk that triggers by a loud clearing breath, then ease. Other obesity-associated dis- the need for intense risk-factor brief awakening. eases are less lethal but still require modification and management appropriate clinical therapy. Obesity of the diseases present: 3. Identify other obesity-associ- also has an aggravating influence on ated diseases. Obese patients several cardiovascular risk factors. Established coronary heart are at increased risk for several Identification of these risk factors is disease (CHD), including a conditions that require detection required to determine the intensity history of , and appropriate management of a clinical intervention. pectoris (stable or unsta- but that generally do not lead ble), coronary artery surgery, to widespread or life-threatening 1. Determine the relative risk or coronary artery procedures consequences. These include status based on overweight (e.g., angioplasty). gynecological abnormalities and obesity parameters. Table Presence of other atherosclerotic (e.g., menorrhagia, amenorrhea), 2 defines relative risk categories diseases, including peripheral osteoarthritis, gallstones and

Men are at increased relative risk for disease if they have a waist circumference greater than 40 inches (102 cm); women are at an increased relative risk if they have a waist circumference greater than 35 inches (88 cm).

11 Risk Factors

Cigarette smoking. Low high-density lipoprotein Family history of premature (HDL) cholesterol (serum CHD (myocardial infarction Hypertension concentration < 35 mg/dL). or sudden death experienced (systolic blood pressure by the father or other male of ≥140 mm Hg or diastolic Impaired fasting glucose first-degree relative at or before blood pressure ≥ 90 mm Hg) (IFG) (fasting plasma glucose 55 years of age, or experienced or current use of antihyperten- between 110 and 125 mg/dL). by the mother or other female sive agents. IFG is considered by many first-degree relative at or before authorities to be an independent 65 years of age). High-risk low-density risk factor for cardiovascular lipoprotein (LDL) cholesterol (macrovascular) disease, thus Age ≥ 45 years for men or (serum concentration justifying its inclusion among age ≥ 55 years for women ≥ 160 mg/dL). A borderline risk factors contributing to (or postmenopausal). high-risk LDL-cholesterol high absolute risk. IFG is (130 to 159 mg/dL) plus two well established as a risk or more other risk factors also factor for type 2 diabetes. confers high risk.

their complications, and stress listed in the chart above. The type 2 diabetes.31 Physical inac- incontinence. Although obese presence of high absolute risk tivity exacerbates the severity of patients are at increased risk for increases the attention paid to other risk factors, but it also has gallstones, the risk of this dis- cholesterol-lowering therapy29 been shown to be an indepen- ease increases during periods of and blood pressure manage- dent risk factor for all-cause rapid weight reduction. ment.30 mortality or CVD mortality.32,33 Although physical inactivity is 4. Identify cardiovascular risk Other risk factors deserve special not listed as a risk factor that factors that impart a high consideration because their pres- modifies the intensity of therapy absolute risk. Patients can be ence heightens the need for weight required for elevated cholesterol classified as being at high reduction in obese persons. or blood pressure, increased absolute risk for obesity-related physical activity is indicated for disorders if they have three or Physical inactivity imparts an management of these conditions more of the multiple risk factors increased risk for both CVD and (please see the Adult Treatment

12 Risk Factors and Weight Loss Conversely, the presence of Risk Factor Management In overweight and obese persons physical inactivity in an obese weight loss is recommended to person warrants intensified Management options of risk accomplish the following: efforts to remove excess body factors for preventing CVD, weight because physical inac- diabetes, and other chronic Lower elevated blood pressure tivity and obesity both heighten diseases are described in detail in in those with high blood pressure. disease risks. other reports. For details on the management of serum cholesterol Lower elevated blood glucose Obesity is commonly and other lipoprotein disorders, levels in those with type accompanied by elevated refer to the National Cholesterol 2 diabetes. serum triglycerides. Education Program’s Second Triglyceride-rich lipoproteins Report of the Expert Panel on the Lower elevated levels of total may be directly atherogenic, Detection, Evaluation, and cholesterol, LDL-cholesterol, and they are also the most Treatment of High Blood and triglycerides, and raise low common manifestation of Cholesterol in Adults (Adult levels of HDL-cholesterol in the atherogenic lipoprotein Treatment Panel II, ATP II).29 For the those with dyslipidemia. phenotype (high triglycerides, treatment of hypertension, see the small LDL particles, and low National High Blood Pressure HDL-cholesterol levels).34 In Education Program’s Sixth Report the presence of obesity, high of the Joint National Committee on Panel II [ATP II29] of the serum triglycerides are common- the Prevention, Detection, National Cholesterol Education ly associated with a clustering Evaluation, and Treatment of High Program and the Sixth Report of of metabolic risk factors known Blood Pressure (JNC VI).30 the Joint National Committee on as the the Prevention, Detection, (atherogenic lipoprotein See the Additional Resources Evaluation, and Treatment of phenotype, hypertension, list for ordering information from High Blood Pressure [JNC VI30]). resistance, glucose the National Heart, Lung, and Increased physical activity is intolerance, and prothrombotic Blood Institute (see Appendix L). especially needed in obese states). Thus, in obese patients, patients because it promotes elevated serum triglycerides weight reduction as well as are a marker for increased weight maintenance, and cardiovascular risk. favorably modifies obesity- associated risk factors.

13

Evaluation and Treatment Strategy

hen health care practitioners encounter patients in the clinical setting,

opportunities exist for identifying overweight and obesity and their W accompanying risk factors, as well as for initiating treatments for reducing weight, risk factors, and chronic diseases such as CVD and type 2 diabetes. When

assessing a patient for treatment of overweight and obesity, consider the patient’s weight, waist

circumference, and presence of risk factors. The strategy for the evaluation and treatment of

overweight patients is presented in Figure 4 (Treatment Algorithm). This algorithm applies

only to the assessment for overweight and obesity; it does not reflect the overall evaluation of

other conditions and diseases performed by the clinician. Therapeutic approaches for choles-

terol disorders and hypertension are described in ATP II and JNC VI, respectively.29,30 In over-

weight patients, control of cardiovascular risk factors deserves the same emphasis as weight

loss therapy. Reduction of risk factors will reduce the risk for CVD, whether or not weight loss

efforts are successful. Figure 4. Each step (designated by a box) in this process is reviewed in * Treatment Algorithm this section and expanded upon in subsequent sections.

Calculate BMI as follows:

1 Patient encounter weight (kg) BMI = height squared (m2)

If pounds and inches are used: 2 Hx of ≥ 25 BMI? weight (pounds) x 703 BMI = height squared (inches2) Ye s

3 BMI measured in past 2 years?

5 • Measure weight, BMI ≥ 25 OR waist 6 height, and waist 4 circumference > 35 Ye s Assess risk factors circumference in (88 cm) (F) > 40 in • Calculate BMI (102 cm) (M)

No

14 Hx BMI ≥ 25? Ye s

No

Brief reinforcement/ Advise to maintain 15 educate on weight 13 weight/address other management risk factors

Periodic weight, BMI, and 16 waist circumference check

High Risk Waist Circumference Men >40 in (>102 cm) Women >35 in (>88cm)

16 7 BMI ≥ 30 OR {[BMI 25 to 29.9 OR waist circumference Ye s > 35 in (F) > 40 in 8 (M)] AND ≥ 2 risk factors} Clinician and patient devise goals and treatment strategy No for weight loss and risk 12 factor control Does patient want Ye s to lose weight? 9 Progress Ye s No being made/goal No achieved?

Maintenance counseling: • Dietary therapy Assess reasons for 11 10 • Behavior therapy failure to lose weight • Physical activity

Examination

Treatment

* This algorithm applies only to the assessment for overweight and obesity and sub- sequent decisions based on that assessment. It does not reflect any initial overall assessment for other cardiovascular risk factors that are indicated.

17 Each step (designated by a box) in the treatment algorithm is reviewed in this section and expanded upon in subsequent sections.

1 Patient encounter 4 Measure weight, damage presents the greatest Any interaction between a height, waist circumference; urgency. Because the major risk of health care practitioner (generally calculate BMI obesity is indirect (obesity elicits or a physician, nurse practitioner, or Weight must be measured so BMI aggravates hypertension, dyslipi- physician’s assistant) and a patient can be calculated. Most charts are demias, and type 2 diabetes; each that provides the opportunity to based on weights obtained with of these leads to cardiovascular assess a patient’s weight status the patient wearing undergarments complications), the management and provide advice, counseling, and no shoes. of obesity should be implemented or treatment. in the context of these other risk 5 BMI ≥ 25 OR factors. Although there is no direct 2 History of overweight waist circumference > 35 in evidence that addressing risk factors or recorded BMI ≥ 25 (88 cm) (women) or > 40 in increases weight loss, treating the Seek to determine whether the (102 cm) (men) risk factors through weight loss is patient has ever been overweight. These cutoff values divide a recommended strategy. The risk A simple question such as “Have overweight from normal weight factors that should be considered are you ever been overweight?” may and are consistent with other provided on pages 11–13. A nutri- accomplish this goal. Questions national and international tion assessment will also help to directed toward weight history, guidelines. The relationship assess the diet and physical activity dietary habits, physical activities, between weight and mortality is habits of overweight patients. and may provide useful J-shaped, and evidence suggests information about the origins of that the right side of the “J” begins 7 BMI ≥ 30 OR ([BMI 25 to obesity in particular patients. to rise at a BMI of 25. Waist 29.9 OR waist circumference circumference is incorporated as > 35 in (88 cm) (women) or 3 BMI measured an “or” factor because some > 40 in (102 cm) (men)] in past 2 years patients with a BMI lower than AND ≥ 2 risk factors) For those who have not been 25 will have a disproportionate The panel recommends that all overweight, a 2-year interval is amount of abdominal fat, which patients who meet these criteria appropriate for the reassessment increases their cardiovascular risk should attempt to lose weight. of BMI. Although this timespan is despite their low BMI (see pages However, it is important to ask the not evidence-based, it is a reason- 9–10). These abdominal patient whether or not he or she able compromise between the circumference values are not wants to lose weight. Those with need to identify weight gain at necessary for patients with a a BMI between 25 and 29.9 kg/m2 an early stage and the need to BMI ≥ 35 kg/m2. and who have one or no risk factors limit the time, effort, and cost should work on maintaining their of repeated measurements. 6 Assess risk factors current weight rather than embark Risk assessment for CVD and on a weight reduction program. diabetes in a person with evident The panel recognizes that the obesity will include special decision to lose weight must be considerations for the medical made in the context of other risk history, physical examination, and factors (e.g., quitting smoking is laboratory examination. Detection more important than losing weight) of existing CVD or end-organ and patient preferences. 18 8 Clinician and patient be attempted for at least 6 9 Progress being devise goals months before considering made/goal achieved The decision to lose weight must pharmacotherapy. In addition, During the acute weight loss be made jointly between the pharmacotherapy should be period and at the 6-month and clinician and patient. Patient considered as an adjunct to 1-year followup visits, patients involvement and investment is lifestyle therapy for patients should be weighed, their BMI crucial to success. The patient may with a BMI 30 kg/m2 and who have should be calculated, and their choose as a goal not to lose weight no concomitant obesity-related risk progress should be assessed. If at but rather to prevent further weight factors or diseases. Pharmaco- any time it appears that the program gain. As an initial goal for weight therapy may also be considered for is failing, a reassessment should loss, the panel recommends the loss patients with a BMI 27 kg/m2 and take place to determine the reasons of 10 percent of baseline weight at who have concomitant obesity- (see Box 10). If pharmacotherapy a rate of 1 to 2 pounds per week related risk factors or diseases. The is used, appropriate monitoring for and the establishment of an energy risk factors or diseases considered side effects is recommended (see deficit of 500 to 1,000 kcal/ day important enough to warrant pages 35–37). If a patient can (see page 23). For individuals who pharmacotherapy at a BMI of 27 achieve the recommended 10-per- are overweight, a deficit of 300 to to 29.9 kg/m2 are hypertension, cent reduction in body weight 500 kcal/day may be more appro- dyslipidemia, CHD, type 2 diabetes, within 6 months to 1 year, this priate, providing a weight loss of and sleep apnea. change in weight can be considered about 0.5 pounds per week. Also, good progress. The patient can there is evidence that an average of Two drugs approved for weight loss then enter the phase of weight 8 percent of body weight can be by the FDA for long-term use are maintenance and long-term lost over 6 months. Since this sibutramine and orlistat. However, monitoring. It is important for the observed average weight loss sibutramine should not be used in practitioner to recognize that some includes people who do not lose patients with a history of hyperten- persons are more apt to lose or gain weight, an individual goal of 10 sion, CHD, congestive , weight on a given regimen; this percent is reasonable. After arrhythmias, or stroke. Certain phenomenon cannot always be 6 months, most patients will equili- patients may be candidates for attributed to the degree of compli- brate (caloric intake balancing weight loss surgery. ance. However, if significant energy expenditure); thus, they obesity persists and the obesity- will require an adjustment of their Each component of weight loss associated risk factors remain, an energy balance if they are to lose therapy should be introduced to effort should be made to reinstitute more weight (see page 24). the patient briefly. The selection weight loss therapy to achieve fur- of weight loss methods should be ther weight reduction. Once the limit The three major components of made in the context of patient pref- of weight loss has been reached, the weight loss therapy are dietary ther- erences, analysis of failed attempts, practitioner is responsible for long- apy, increased physical activity, and and consideration of available term monitoring of risk factors and behavior therapy (see pages 26 to resources. for encouraging the patient to main- 34). These lifestyle therapies should tain the level of weight reduction.

19 10 Assess reasons for failure 11 Maintenance counseling not obese and who wish to focus on to lose weight Evidence suggests that more than 80 maintenance of their current weight, If a patient fails to achieve the rec- percent of the individuals who lose should be provided with counseling ommended 10-percent reduction in weight will gradually regain it. and advice so their weight does not body weight within 6 months or Patients who continue to use weight increase. An increase in weight 1 year, a reevaluation is required. A maintenance programs have a greater increases their health risk and critical question to consider is chance of keeping weight off. should be prevented. The clinician whether the patient’s level of motiva- Maintenance includes continued con- should actively promote prevention tion is high enough to continue clini- tact with the health care practitioner strategies, including enhanced atten- cal therapy. If motivation is high, for education, support, and medical tion to diet, physical activity, and revise goals and strategies (see monitoring (see page 24). behavior therapy. See Box 6 for Box 8). If motivation is not high, addressing other risk factors; even clinical therapy should be discontin- 12 Does the patient want if weight loss cannot be addressed, ued, but the patient should be to lose weight? other risk factors should be treated. encouraged to embark on efforts to Patients who do not want to lose lose weight or to avoid further weight but who are overweight 14 History of BMI ≥ 25 weight gain. Even if weight loss (BMI 25 to 29.9), without a high This box differentiates those who therapy is stopped, risk factor man- waist circumference and with one or presently are not overweight and agement must be continued. Failure no cardiovascular risk factors, should never have been from those with a to achieve weight loss should prompt be counseled regarding the need to history of overweight (see Box 2). the practitioner to investigate the fol- maintain their weight at or below its lowing: (1) energy intake (i.e., present level. Patients who wish to 15 Brief reinforcement dietary recall including alcohol lose weight should be guided accord- Those who are not overweight and intake and daily intake logs), ing to Boxes 8 and 9. The justifica- never have been should be advised of (2) energy expenditure (physical tion of offering these overweight the importance of staying in this cat- activity diary), (3) attendance at psy- patients the option of maintaining egory. chological/behavioral counseling ses- (rather than losing) weight is that sions, (4) recent negative life events, their health risk, although higher 16 Periodic weight, BMI, (5) family and societal pressures, than that of persons with a BMI and waist circumference check and (6) evidence of detrimental psy- < 25, is only moderately increased Patients should receive periodic chiatric problems (e.g., , (see page 11). monitoring of their weight, BMI, and disorder). If attempts waist circumference. Patients who to lose weight have failed, and the 13 Advise to maintain are not overweight or have no history BMI is ≥ 40, or 35 to 39.9 with weight/address other of overweight should be screened for comorbidities or significant reduc- risk factors weight gain every 2 years. This tion in quality of life, surgical thera- Patients who have a history of timespan is a reasonable compromise py should be considered. overweight and who are now at an between the need to identify weight appropriate body weight, and those gain at an early stage and the need to patients who are overweight but limit the time, effort, and cost of repeated measurements. Ready or Not: Predicting Weight Loss

redicting a patient’s readiness two groups tend to lose comparable for weight loss and identifying percentages of initial weight. Studies Exclusion From Ppotential variables associated have not found that weight cycling Weight Loss Therapy with weight loss success is an impor- is associated with a poorer treatment tant step in understanding the needs outcome. Behavioral predictors of Patients for whom weight loss of patients. However, it may be easi- weight loss have proved to be less therapy is not appropriate are er said than done. Researchers have consistent. Depression, anxiety, or most pregnant or lactating tried for years with some success to binge eating may be associated women, persons with a serious identify predictors of weight loss. with suboptimal weight loss, though uncontrolled psychiatric illness Such predictors would allow health findings have been contradictory. such as a major depression, and care practitioners, before treatment, Similarly, measures of readiness or patients who have a variety of to identify individuals who have a motivation to lose weight have gen- serious illnesses and for whom high or low likelihood of success. erally failed to predict outcome. By caloric restriction might exacer- Appropriate steps potentially could contrast, self-efficacy—a patient’s bate the illness. Patients with be taken to improve the chances of report that she or he can perform active substance abuse and those patients in the latter category. Among the behaviors required for weight with a history of biological variables, initial body loss—is a modest but consistent nervosa or should weight and resting metabolic rate predictor of success. Several stud- be referred for specialized care. (RMR) are both positively related ies have also suggested that posi- to weight loss. Heavier individuals tive coping skills contribute to tend to lose more weight than do weight control. lighter individuals, although the

Consider a patient’s readi- ness for weight loss and identify potential variables associated with weight loss success.

21 A Brief Behavioral Assessment

Clinical experience suggests that In such cases, treatment may be the need for psychological or health care practitioners briefly delayed until the stressor passes, thus nutritional counseling. consider the following issues when increasing the chances of success. assessing an obese individual’s Briefly assess the patient’s mood to “Does the individual understand readiness for weight loss: rule out major depression or other the requirements of treatment complications. Reports of poor and believe that he or she can “Has the individual sought weight sleep, a low mood, or lack of plea- fulfill them?” Practitioner and loss on his or her own initiative?” sure in daily activities can be fol- patient together should select a Weight loss efforts are unlikely to lowed up to determine whether course of treatment and identify be successful if patients feel that intervention is needed: it is usually the changes in eating and activity they have been forced into treatment best to treat the mood disorder habits that the patient wishes to by family members, their employer, before undertaking weight reduction. make. It is important to select or their physician. Before initiating activities that patients believe they treatment, health care practitioners “Does the individual have an can perform successfully. Patients should determine whether patients , in addition to should feel that they have the recognize the need and benefits of obesity?” Approximately 20 per- time, desire, and skills to adhere weight reduction and want to lose cent to 30 percent of obese indi- to a program that you have weight. viduals who seek weight reduc- planned together. tion at university clinics suffer “What events have led the patient from binge eating. This involves “How much weight does the to seek weight loss now?” eating an unusually large amount patient expect to lose? What Responses to this question will pro- of food and experiencing loss of other benefits does he or she vide information about the patient’s control while . Binge anticipate?” Obese individuals weight loss motivation and goals. In eaters are distressed by their typically want to lose 2 to 3 times most cases, individuals have been overeating, which differentiates the 8 to 15 percent often observed obese for many years. Something them from persons who report and are disappointed when they do has happened to make them seek that they “just enjoy eating and eat not. Practitioners must help patients weight loss. The motivator differs too much.” Ask patients which understand that modest weight from person to person. meals they typically eat and the losses frequently improve health times of consumption. Binge complications of obesity. Progress “What are the patient’s stress eaters usually do not have a regu- should then be evaluated by level and mood?” There may not lar meal plan; instead, they snack achievement of these goals, which be a perfect time to lose weight, throughout the day. Although may include sleeping better, having but some are better than others. some of these individuals respond more energy, reducing pain, Individuals who report higher-than- well to weight reduction therapy, and pursuing new hobbies or usual stress levels with work, family the greater the patient’s distress or rediscovering old ones, particularly life, or financial problems may not depression, or the more chaotic when weight loss slows and be able to focus on weight control. the eating pattern, the more likely eventually stops.

22 Management of Overweight and Obesity

he initial goal of weight loss weight loss. The latter is counter- therapy for overweight productive in terms of time, cost, Goals for Weight Loss Tpatients is a reduction in and self-esteem. and Management body weight of about 10 percent. If this target is achieved, considera- Rate of Weight Loss The following are general goals tion may be given to further weight A reasonable time to achieve a for weight loss and management: loss. In general, patients will wish 10-percent reduction in body weight to lose more than 10 percent of is 6 months of therapy. To achieve a Reduce body weight body weight; they will need to be significant loss of weight, an energy counseled about the appropriate- deficit must be created and main- Maintain a lower body weight ness of this initial goal.35,36 Further tained. Weight should be lost at a over the long term weight loss can be considered after rate of 1 to 2 pounds per week, this initial goal is achieved and based on a between Prevent further weight gain maintained for 6 months. The ratio- 500 and 1,000 kcal/day. After (a minimum goal) nale for the initial 10-percent goal 6 months, theoretically, this caloric is that a moderate weight loss of deficit should result in a loss of this magnitude can significantly between 26 and 52 pounds. decrease the severity of obesity- However, the average weight loss It is difficult for most patients to associated risk factors. It is better actually observed over this time is continue to lose weight after 6 to maintain a moderate weight loss between 20 and 25 pounds. A greater months because of changes in rest- over a prolonged period than to rate of weight loss does not yield a ing metabolic rates and problems regain weight from a marked better result at the end of 1 year.37 with adherence to treatment strate- gies. Because energy requirements decrease as weight is decreased, diet and physical activity goals need to be revised so that an energy deficit is created at the lower weight, allowing the patient to continue to lose weight. To achieve additional weight loss, the patient must further

A 10 percent reduction in body weight reduces disease risk factors. Weight should be lost at a rate of 1 to 2 pounds per week based on a calorie deficit of 500–1,000 kcal/day.

23 decrease calories and/or increase The primary care practitioner and therapy) must be continued indefi- physical activity. Many studies show patient should recognize that, at this nitely; otherwise, excess weight that rapid weight reduction is almost point, weight maintenance, the sec- will likely be regained. Numerous always followed by gain of the ond phase of the weight loss effort, strategies are available for motivat- lost weight. Moreover, with rapid should take priority. Successful ing the patient; all of these require weight reduction, there is an weight maintenance is defined as that the practitioner continue to increased risk for gallstones and, a regain of weight that is less than communicate frequently with the possibly, electrolyte abnormalities. 6.6 pounds (3 kg) in 2 years and patient. Long-term monitoring and a sustained reduction in waist encouragement can be accom- Weight Maintenance at a circumference of at least 1.6 inches plished in several ways: by regular Lower Weight (4 cm). If a patient wishes to lose clinic visits, at group meetings, or Once the goals of weight loss have more weight after a period of via telephone or e-mail. The longer been successfully achieved, mainte- weight maintenance, the procedure the weight maintenance phase nance of a lower body weight for weight loss, outlined above, can be sustained, the better the becomes the major challenge. In the can be repeated. prospects for long-term success in past, obtaining the goal of weight weight reduction. Drug therapy loss was considered the end of After a patient has achieved the with either of the two FDA- weight loss therapy. Unfortunately, targeted weight loss, the combined approved drugs for weight loss once patients are dismissed from modalities of therapy (dietary thera- may also be helpful during the clinical therapy, they frequently py, physical activity, and behavior weight maintenance phase. regain the lost weight.

After 6 months of weight loss, the rate at which the weight is lost usually declines, then plateaus.

Long-term monitoring and encouragement to maintain weight loss requires regular clinic visits, group meetings, or encouragement via telephone or e-mail.

24 Techniques

ffective weight control calorie intake but also reduces satu- Weight management techniques need involves multiple tech- rated fat, total fat, and cholesterol to take into account the needs of indi- niques and strategies intake in order to help lower high vidual patients so they should be cul- including dietary therapy, blood cholesterol levels. The diet also turally sensitive and incorporate the physical activity, behavior includes the current recommenda- patient’s perspectives and characteris- Etherapy, pharmacotherapy, and tions for sodium, calcium and fiber tics. Treatment of overweight and surgery as well as combinations of intakes. Increased physical activity is obesity is to be taken seriously since these strategies. Relevant treatment not only important for weight loss it involves treating an individual’s strategies can also be used to foster and weight loss maintenance but also disease over the long term as well as long-term weight control and preven- impacts on other comorbidities and making modifications to a way of life tion of weight gain. risk factors such as high blood pres- for entire families. sure, and high blood cholesterol lev- Some strategies such as modifying els. Reducing body weight in over- Table 3 illustrates the therapies dietary intake and physical activity weight and obese patients not only appropriate for use at different BMI can also impact on obesity-related helps reduce the risk of these comor- levels taking into account the comorbidities or risk factors. Since bidities from developing but also existence of other comorbidities the diet recommended is a low calo- helps in their management. or risk factors. rie Step-1 diet, it not only modifies

Table 3 A Guide to Selecting Treatment BMI category Treatment 25–26.9 27–29.9 30-34.9 35–39.9 ≥ 40

Diet, physical activity, With With + + + and behavior therapy comorbidities comorbidities

Pharmacotherapy With + + + comorbidities Surgery With comorbidities

Prevention of weight gain with lifestyle therapy is indicated in any patient with a BMI ≥ 25 kg/m2, even without comorbidities, while weight loss is not necessarily recommended for those with a BMI of 25–29.9 kg/m2 or a high waist circumference, unless they have two or more comorbidities. Combined therapy with a low-calorie diet (LCD), increased physical activity, and behavior therapy provide the most successful intervention for weight loss and weight maintenance. Consider pharmacotherapy only if a patient has not lost 1 pound per week after 6 months of combined lifestyle therapy. The + represents the use of indicated treatment regardless of comorbidities.

25 Dietary Therapy

n the majority of overweight and The centerpiece of dietary therapy Low calorie diet (LCD) obese patients, adjustment of the for weight loss in overweight or diet will be required to reduce obese patients is a low calorie diet 1,000 to 1,200 kcal/day I for most women caloric intake. Dietary therapy (LCD). This diet is different from a includes instructing patients in the very low calorie diet (VLCD) (less 1,200 to 1,600 kcal/day modification of their diets to than 800 kcal/day). The recom- should be chosen for men achieve a decrease in caloric intake. mended LCD in this guide, i.e., the A diet that is individually planned Step I Diet, also contains the nutri- Successful weight reduction by to help create a deficit of 500 to ent composition that will decrease LCDs is more likely to occur when 1,000 kcal/day should be an integral other risk factors such as high blood consideration is given to a patient’s part of any program aimed at cholesterol and hypertension. The food preferences in tailoring a achieving a weight loss of 1 to composition of the diet is presented particular diet. Care should be 2 pounds per week. A key element in Table 4. In general, diets contain- taken to ensure that all of the of the current recommendation is ing 1,000 to 1,200 kcal/day should recommended dietary allowances the use of a moderate reduction in be selected for most women; a diet are met; this may require the use caloric intake, which is designed to between 1,200 kcal/day and 1,600 of a dietary or supplement. achieve a slow, but progressive, kcal/day should be chosen for Dietary education is necessary weight loss. Ideally, caloric intake men and may be appropriate for to assist in the adjustment to a should be reduced only to the level women who weigh 165 pounds or LCD. Educational efforts should that is required to maintain weight more, or who exercise regularly. pay particular attention to the at a desired level. If this level of If the patient can stick with the following topics: caloric intake is achieved, excess 1,600 kcal/day diet but does not Energy value of different . weight will gradually decrease. In lose weight you may want to try the Food composition—, practice, somewhat greater caloric 1,200 kcal/day diet. If a patient carbohydrates (including dietary deficits are used in the period of on either diet is hungry, you may fiber), and . active weight loss, but diets with a want to increase the calories by Evaluation of nutrition labels to very low-calorie content are to be 100 to 200 per day. determine caloric content and food avoided. Finally, the composition composition. of the diet should be modified VLCDs should not be used New habits of purchasing—give to minimize other cardiovascular routinely for weight loss therapy preference to low-calorie foods. risk factors. because they require special moni- Food preparation—avoid adding toring and supplementation.50 high-calorie ingredients during VLCDs are used only in very limit- cooking (e.g., fats and oils). ed circumstances by specialized Avoiding of See Appendices B-H for diets practitioners experienced in their high-calorie foods (both high-fat and information on physical use. Moreover, clinical trials show and high-carbohydrate foods). activity that you can use that LCDs are as effective as Adequate water intake. with your patients. VLCDs in producing weight loss Reduction of portion sizes. after 1 year.37 Limiting alcohol consumption.

26 Table 4 Low-Calorie Step I Diet

Nutrient Recommended Intake Calories1 Approximately 500 to 1,000 kcal/day reduction from usual intake Total fat2 30 percent or less of total calories Saturated fatty acids3 8 to 10 percent of total calories Monounsaturated fatty acids Up to 15 percent of total calories Polyunsaturated fatty acids Up to 10 percent of total calories Cholesterol3 <300 mg/day Protein4 Approximately 15 percent of total calories Carbohydrate5 55 percent or more of total calories Sodium chloride No more than 100 mmol/day (approximately 2.4 g of sodium or approximately 6 g of sodium chloride) Calcium6 1,000 to 1,500 mg/day Fiber 5 20 to 30 g/day

1. A reduction in calories of 500 to 1,000 kcal/day will help achieve a weight loss of 1 to 2 pounds/week. Alcohol provides unneeded calories and displaces more nutritious foods. Alcohol consumption not only increases the number of calories in a diet but has been associated with obesity in epidemiologic studies38-41 as well as in experimental studies.42-45 The impact of alcohol calories on a person’s overall caloric intake needs to be assessed and appropriately controlled. 2. Fat-modified foods may provide a helpful strategy for lowering total fat intake but will only be effective if they are also low in calories and if there is no compensation by calories from other foods. 3. Patients with high blood cholesterol levels may need to use the Step II diet to achieve further reductions in LDL-cholesterol levels; in the Step II diet, saturated fats are reduced to less than 7 percent of total calories, and cholesterol levels to less than 200 mg/day. All of the other nutrients are the same as in Step I. 4. should be derived from plant sources and lean sources of animal protein. 5. Complex carbohydrates from different vegetables, fruits, and whole grains are good sources of vitamins, minerals, and fiber. A diet rich in soluble fiber, including oat bran, legumes, barley, and most fruits and vegetables, may be effective in reducing blood cholesterol levels. A diet high in all types of fiber may also aid in weight management by promoting satiety at lower levels of calorie and fat intake. Some authorities recommend 20 to 30 grams of fiber daily, with an upper limit of 35 grams.46-48 6. During weight loss, attention should be given to maintaining an adequate intake of vitamins and minerals. Maintenance of the recommended calcium intake of 1,000 to 1,500 mg/day is especially important for women who may be at risk of osteoporosis.49

27 Physical Activity

hysical activity should be an may require supervision for some cross-country skiing, aerobic danc- integral part of weight loss people. The need to avoid injury dur- ing, and jumping rope. Jogging pro- Ptherapy and weight mainte- ing physical activity is a high priori- vides a high-intensity aerobic exer- nance. Initially, moderate levels of ty. Extremely obese persons may cise, but it can lead to orthopedic physical activity for 30 to 45 min- need to start with simple injury. If jogging is desired, the utes, 3 to 5 days per week, should that can be intensified gradually. The patient’s ability to do this must first be encouraged. practitioner must decide whether be assessed. The availability of a exercise testing for cardiopulmonary safe environment for the jogger is An increase in physical activity is an disease is needed before embarking also a necessity. Competitive sports, important component of weight loss on a new physical activity regimen. such as tennis and volleyball, can therapy,31 although it will not lead to This decision should be based provide an enjoyable form of physi- a substantially greater weight loss on a patient’s age, symptoms, and cal activity for many, but again, than diet alone over 6 months.51 concomitant risk factors. care must be taken to avoid injury, Most weight loss occurs because of especially in older people. decreased caloric intake. Sustained For most obese patients, physical physical activity is most helpful in activity should be initiated slowly, As the examples listed in Table 5 the prevention of weight regain.52,53 and the intensity should be show, a moderate amount of physi- In addition, physical activity is bene- increased gradually. Initial activities cal activity can be achieved in a ficial for reducing risks for cardio- may be increasing small tasks of variety of ways. People can select vascular disease and type 2 diabetes, daily living such as taking the stairs activities that they enjoy and that beyond that produced by weight or walking or swimming at a slow fit into their daily lives. Because reduction alone. Many people live pace. With time, depending on amounts of activity are functions of sedentary lives, have little training progress, the amount of weight lost, duration, intensity, and frequency, or skills in physical activity, and are and functional capacity, the patient the same amounts of activity can difficult to motivate toward increas- may engage in more strenuous be obtained in longer sessions of ing their activity. For these reasons, activities. Some of these include moderately intense activities (such starting a physical activity regimen fitness walking, cycling, rowing, as brisk walking) as in shorter ses- sions of more strenuous activities (such as ). All adults should set a long-term goal to A regimen of daily walking is an accumulate at least attractive form of physical activity for many people, particularly those 30 minutes or more who are overweight or obese. The of moderate-intensity patient can start by walking 10 min- utes, 3 days a week, and can build physical activity on to 30 to 45 minutes of more intense most, and preferably walking at least 3 days a week and all, days of the week. increase to most, if not all, days.52,53 With this regimen, an additional

28 Table 5 Examples of Moderate Amounts of Physical Activity*

Common Chores Sporting Activities Less Washing and waxing a car for 45–60 minutes Playing volleyball for 45–60 minutes Vigorous, More Time† Washing windows or floors for 45–60 minutes Playing touch football for 45 minutes

3 Gardening for 30–45 minutes Walking 1 /4 miles in 35 minutes (20 min/mile) Wheeling self in wheelchair for 30–40 minutes (shooting baskets) for 30 minutes

1 Pushing a stroller 1 /2 miles in 30 minutes Bicycling 5 miles in 30 minutes Raking leaves for 30 minutes Dancing fast (social) for 30 minutes Walking 2 miles in 30 minutes (15 min/mile) Water aerobics for 30 minutes Shoveling snow for 15 minutes Swimming laps for 20 minutes Stairwalking for 15 minutes Basketball (playing a game) for 15–20 minutes More Jumping rope for 15 minutes Vigorous, Less Time 1 Running 1 /2 miles in 15 minutes (15 min/mile)

* A moderate amount of physical activity is roughly equivalent to physical activity that uses approximately 150 calories of energy per day, or 1,000 calories per week. † Some activities can be performed at various intensities; the suggested durations correspond to expected intensity of effort.

100 to 200 kcal/day of physical Reducing sedentary time, i.e., form the activity (e.g., community activity can be expended. Caloric time spent watching television or parks, gyms, pools, and health expenditure will vary depending on playing video games, is another clubs). However, when these the individual’s body weight and approach to increasing activity. sites are not available, an area the intensity of the activity. Patients should be encouraged to of the home can be identified and build physical activities into each perhaps outfitted with equipment This regimen can be adapted to day. Examples include leaving such as a stationary bicycle or a other forms of physical activity, public transportation one stop treadmill. Health care profession- but walking is particularly attractive before the usual one, parking far- als should encourage patients to because of its safety and acces- ther than usual from work or shop- plan and schedule physical activity sibility. With time, a larger weekly ping, and walking up stairs instead 1 week in advance, budget the volume of physical activity can be of taking elevators or escalators. time necessary to do it, and docu- performed that would normally New forms of physical activity ment their physical activity by cause a greater weight loss if it should be suggested (e.g., garden- keeping a diary and recording the were not compensated by a higher ing, walking a dog daily, or new duration and intensity of exercise. caloric intake. athletic activities). Engaging in The following are examples of physical activity can be facilitated activities at different levels of by identifying a safe area to per- intensity. A moderate amount of

29 Behavior Therapy

physical activity is roughly equiv- ehavior therapy provides tion from strangers and, some- alent to physical activity that uses methods for overcoming times, hurtful comments from approximately 150 calories of Bbarriers to compliance with previous health care professionals. energy per day, or 1,000 calories dietary therapy and/or increased The patient with obesity may be per week. physical activity, and these meth- understandably defensive about ods are important components of the problem. For the beginner, or someone who weight loss treatment. The follow- leads a very , ing approach is designed to assist Be careful to communicate very light activity would include the caregiver in delivering behav- a nonjudgmental attitude that increased standing activities, room ior therapy. The importance of distinguishes between the painting, pushing a wheelchair, individualizing behavioral strate- weight problem and the patient yard work, ironing, cooking, and gies to the needs of the patient with the problem. Ask about playing a musical instrument. must be emphasized for behavior the patient’s weight history and therapy, as it was for diet and how obesity has affected his or Light activity would include slow exercise strategies.54 her life. Express your concerns walking (24 min/mile), garage about the health risks associated work, carpentry, house cleaning, In addition, the practitioner must with obesity, and how obesity is child care, golf, sailing, and recre- assess the patient’s motivation to affecting the patient. ational table tennis. enter weight loss therapy and the patient’s readiness to implement Similarly, most providers have had Moderate activity would include the plan. Then the practitioner can some frustrating experiences in walking a 15-minute mile, weed- take appropriate steps to motivate dealing with patients with weight ing and hoeing a garden, carrying the patient for treatment. problems. Appropriate respect for a load, cycling, skiing, tennis, and the difficulty of long-term weight dancing. control may mutate into a reflex- Making the Most of ive sense of futility. When efforts High activity would include the Patient Visit to help patients lose weight are jogging a mile in 10 minutes, unsuccessful, the provider may be walking with a load uphill, tree Consider Attitudes, Beliefs, disappointed and may blame the felling, heavy manual digging, and Histories. patient for the failure, seeing basketball, climbing, and soccer. In the patient-provider interaction, obese people as uniquely noncom- individual histories, attitudes, and pliant and difficult. Providers too Other key activities would beliefs may affect both parties. may feel some antifat prejudice. include flexibility exercises to The diagnosis of obesity is rarely attain full range of joint motion, new or news for the patient. Objectively examine your own strength or resistance exercises, Except for patients with very attitudes and beliefs about obe- and aerobic conditioning. recent weight gain, the patient sity and obese people. brings into the consulting room a Remember, obesity is a chronic history of dealing with a frustrat- disease, like diabetes or hyper- ing, troubling, and visible prob- tension. In a sense, patients are lem. Obese people are often the struggling against their own recipients of scorn and discrimina- body’s coordinated effort to

30 stop them from losing weight. When weight is first brought up, Set Achievable Goals. Remember, compliance with ask what the patient’s weight Setting goals should be a collabo- most long-term treatment regi- goals are. You may indicate that rative activity. From all the avail- mens that require behavior the patient’s weight goals are able dietary and physical activity change is poor. Keep your more ambitious than necessary changes that might be made, a expectations realistic regarding for health improvement, but small number should be selected the ease, amount, speed, and acknowledge that the patient on the basis of their likely impact permanence of weight change. may have many other reasons on weight and health, the patient’s for selecting a different goal. current status, and the patient’s Build a Partnership with Distinguish between the willingness and ability to imple- the Patient. long-term result of weight loss ment them. Once goals are select- The patient must be an active part- and the short-term behavior ed, an action plan can be devised ner in the consultation and must changes (diet, activity, etc.) that to implement change. participate in setting goals for are the means to that end. behavior change. It is the patient Emphasize that the patient will After considering the recom- who must make the changes to judge which specific goals to mended dietary and physical achieve weight loss; the patient attempt and that your review of activity guidelines, the patient already has goals concerning goal attainment is meant to should be encouraged to select weight loss and how to achieve it. evaluate the plan, not the two or three goals that he or These goals may be different from patient. Also, emphasize that the she is willing and able to take those the provider would select. most important thing the patient on. If the patient does not select The provider can be a source of can do is to keep return an area that appears in need of general information, perspective, appointments, even if goals have change, inquire about the per- support, and some measure of not been met. ceived costs and benefits of that guidance but cannot cause the achievement, without presenting patient to meet goals that he or it as mandatory. (“One thing she does not endorse. that seems very important for most patients is physical activi- ty. What are your thoughts about increasing your activity level?”) Assess the patient’s perceived ability to meet a spe- cific goal. (“On a scale from 1 to 10, how confident are you that you can meet Patients must be active this goal?”) partners and participate in Effective goals are specific, setting goals for behavioral attainable, and forgiving (less changes. than perfect). Thus, “exercise more” would become “walk for

31 While in the waiting room, the Focus on positive patient can write down the out- comes of the previous goals, changes and adapt a effects of the various aspects of problem-solving the treatment program (diet, approach toward the activity, medication), items to discuss with you, and possible shortfalls. Weight targets for new goals. In the control is a journey, consultation, a matter-of-degree not a destination. approach can be communicated by questions such as “How many days a week were you able to walk?” rather than “Did you meet your walking goal?” Successes should receive positive attention and praise. If the patient has not successfully met a desired goal, 30 minutes, 3 days a week, for of the patient’s goals and weight emphasize the extent to which now.” Shaping is a behavioral changes. Write down the patient’s he or she approached the goal. technique that involves selecting a goals on the Weekly Food and (“So even though you weren’t series of short-term goals that get Activity Diary (see Appendix K). able to walk 4 days each week, closer and closer to the ultimate you did get out there at least goal (e.g., an initial reduction of Cultivate the Partnership twice a week.”) fat intake from 40 percent of calo- Followup visits are occasions for ries to 35 percent of calories and monitoring health and weight sta- Acknowledge the challenging later to 30 percent). Once the tus and for monitoring responses nature of weight control by adopt- patient has selected a goal, address to any medication regimens. They ing problem-solving responses to briefly what has to be done to also provide the opportunity to goals that are not fully met. achieve it. (“What are the best assess progress toward the goals Emphasize that examining the cir- days for you to take your walks? selected at the previous visit, to cumstances of unmet goals can What time of day is best for you? provide support and additional lead to new and more effective What arrangements will you need information, and to establish goals strategies. (“What do you think to make for child care?”) Provide for the next visit. Imperfect goal interfered with your walking plans the patient with a written behav- attainment is often the norm. Focus on the days you didn’t walk?”) ioral “prescription” listing the on the positive changes, and adopt Emphasize that weight control is selected goals. a problem-solving approach a journey, not a destination, and toward the shortfalls. This is that some missteps are inevitable The Weight and Goal Record achieved by communicating that opportunities to learn how to be (see Appendix J) can be copied the goal, not the patient, is at issue. more successful. for use in the chart to keep track

32 Set goals for the next visit in Help the Patient to Rewards can be used to encour- collaboration with the patient. Modify Behaviors. age attainment of behavioral These goals should be based on Proven behavior modification goals, especially those that have the outcome of the previous techniques can be used to assist been difficult to reach. An effec- goals, consideration of the patients in weight control. Some tive reward is something that is patient-selected targets, and can be communicated readily in desirable, timely, and contingent assessment of the patient’s sta- person or via written materials. on meeting the goal. Patient- tus. If a previous goal was Goals may include the use of administered rewards may be missed by a wide margin, it may one or more of these techniques. tangible (e.g., a movie, music be useful to lower the goal Copy the written handouts in CD, or payment toward buying a somewhat. Appendix J for your patients. more costly item) or intangible (e.g., an afternoon off work or Keep in Touch. Self-monitoring refers to an hour of quiet time away from Frequency of treatment contact is observing and recording some family). Numerous small a major determinant of success at aspect of behavior, such rewards, delivered for meeting weight control, but the contact as caloric intake, exercise smaller goals, are preferable to need not be limited to direct, in- sessions, medication usage, etc., bigger rewards that require a person visits with the provider. or an outcome of these behav- long, difficult effort. Use whatever means exist to iors, such as changes in body maintain frequent contact with weight. Self-monitoring of a Stimulus control changes patients. behavior usually changes the involve learning what social or behavior in the desired direc- environmental cues seem to Encourage patients to drop by tion and can produce real-time encourage undesired eating and between consultations records for your review. Some then modifying those cues. For for a weight check (with the patients find that specific self- example, a patient may learn office nurse or other staff), to monitoring forms make it easi- from reflection or from self- bring in the Weekly Food and er, while others prefer to use monitoring records that he or Activity Diary, to view educa- their own recording system. she is more likely to overeat tional videotapes, or to pick up Recording dietary intake (food while watching television, or other materials. Such interim choices, amounts, times), whenever treats are on display visits can be scheduled or left although seen as a chore by by the office coffeepot, or when on an as-needed basis, depend- some patients, is a very useful around a certain friend. The ing on the patient’s needs and application of self-monitoring. resulting strategies may be to preferences. Educational mater- Although some patients prefer sever the association of eating ial or responses from you or daily weighing and others do from the cue (do not eat while your staff may be transmitted by better with less frequent steps watching television), avoid or mail, e-mail, or telephone. on the scale, regular self- eliminate the cue (leave the cof- A member of your staff may monitoring of weight is crucial fee room immediately after contact the patient between vis- for long-term maintenance. pouring ), or change the its for support. circumstances surrounding the cue (plan to meet with the friend

33 in a setting where food is not Focus on What Matters. history. For example, for a available). In general, visible Improvement of the patient’s patient presenting with a BMI and accessible food items are health is the goal of obesity treat- of 33, hypertension, and a family often cues for unplanned eating. ment. Monitoring progress is a history of type 2 diabetes, a continuous process of motivational chart might include successive Dietary behavior changes can importance to the patient and measures of weight, BMI, waist make it easier to eat less without provider. Simple, clear records of circumference, blood pressure, feeling deprived. An important body weight, relevant risk factors, and fasting blood glucose. Copy change is to slow the rate of other health parameters, and goal these records for the patient. eating to allow satiety signals to attainment should be kept. Provide the patient with a written begin to develop before the end behavioral “prescription” listing of the meal. Another tactic is to Use simple charts or graphs the selected goals. The Weight use smaller plates so that moderate to summarize changes in weight and Goal Record (see Appendix portions do not appear meager. and the associated risk factors J) can be copied for use in the Changing the scheduling of that were present initially or chart to keep track of the patient’s eating can be helpful for patients suggested by the patient’s family goals and weight changes. who skip or delay meals, then overeat later.

Focus on What Matters

Improvement of the patient’s health is the goal of obesity treatment. Monitoring progress is a continuous process of motivational importance to the patient and provider.

34 Pharmacotherapy

eight loss drugs available until November 1997, dopamine, norepinephrine, or sero- approved by the FDA when the FDA approved sibu- tonin into the synaptic neural cleft, W for long-term use may tramine for long-term use in obesity. by inhibiting the reuptake of these be useful as an adjunct to diet and In April 1999, the FDA approved into the , physical activity for patients with orlistat for long-term use. or by a combination of both a BMI ≥ 30 and without concomi- mechanisms. Sibutramine inhibits tant obesity-related risk factors The purpose of weight loss and the reuptake of norepinephrine or diseases. Drug therapy may also weight maintenance is to reduce and serotonin. Orlistat is not an be useful for patients with a health risks. If weight is regained, appetite suppressant and has a BMI ≥ 27 who also have concomi- health risks increase. A majority of different mechanism of action; it tant obesity-related risk factors patients who lose weight regain blocks about one-third of fat or diseases. it,57 so the challenge to the patient absorption. Very few trials longer and the practitioner is to maintain than 6 months have been done Drugs may be used as weight loss. Because of the ten- with any of the new drugs. adjunctive therapy in dency to regain weight after patients with a BMI ≥ 30 weight loss, the use of long-term These drugs are modestly effective or ≥ 27 with other risk medication to aid in the treatment in their ability to produce weight factors or diseases. of obesity may be indicated for loss. Net weight loss attributable carefully selected patients. to drugs has generally been report- Our thinking about drug ed to range from 2 to 10 kilograms therapy has undergone radical The drugs used to promote weight changes over the past few years. loss have been anorexiants or Following the publication of the appetite suppressants. Three classes 4-year trials with of anorexiant drugs have been and by Weintraub in developed, all of which affect neu- 1992 and the discovery of , rotransmitters in the brain. They an adipose-tissue , drug may be designated as follows: therapy began to change from (1) those that affect catecholamines, short-term to long-term use. such as dopamine and norepineph- , fenfluramine, rine; (2) those that affect serotonin; and the combination of phenter- and (3) those that affect more than mine and fenfluramine were used one . These drugs long term. However, reported con- work by increasing the secretion of cerns about unacceptable side effects, such as regurgitant valvu- Drugs used only lar lesions of the heart,55 led to the withdrawal of dexfenfluramine as part of a program that and fenfluramine from the market includes diet, physical in September 1997.56 No drug approved by the FDA for use activity, and behavior therapy. beyond 3 months remained

35 Table 6 Weight Loss Drugs*

Drug Dose Action Adverse Effects

Sibutramine 5, 10,15 mg Norepinephrine, Increase in heart rate and (Meridia) 10 mg po qd to start, dopamine, and sero- blood pressure. may be increased to 15 tonin reuptake inhibitor. mg or decreased to 5 mg

Orlistat 120 mg Inhibits pancreatic Decrease in absorption of (Xenical) 120 mg po tid before lipase, decreases fat fat-soluble vitamins; soft meals absorption. stools and anal leakage.

* plus , and have also been tested for weight loss but are not approved for use in the treatment of obesity. , diethylpropion, phentermine, , and are approved for only short-term use for the treatment of obesity. Herbal preparations are not recommended as part of a weight loss program. These preparations have unpredictable amounts of active ingredients and unpredictable, and potentially harmful, effects.

(4.4 to 22 lbs), although some in the absorption of fat-soluble vit- rations are not recommended as patients lose significantly more amins, and oily and loose stools part of a weight loss program. weight. It is not possible to predict are side effects; a multivitamin These preparations have unpre- precisely how much weight an supplement is recommended when dictable amounts of active ingredi- individual may lose. Most of the taking this drug. Side effects from ents and unpredictable, weight loss occurs within the first these drugs are generally mild and and potentially harmful, effects. 6 months of therapy. may improve with continued use, although their persistence may If a patient has not lost the recom- Adverse effects noted for sibu- result in discontinuation of drug mended 1 pound per week after tramine therapy include increases treatment. Table 6 provides the at least 6 months on a weight loss in blood pressure and pulse.58 dose, action, and adverse effects of regimen that includes an LCD, People with high blood pressure, sibutramine and orlistat. increased physical activity, and CHD, congestive heart failure, behavior therapy, then careful arrhythmias, or history of stroke Ephedrine plus caffeine, and consideration may be given to should not take sibutramine. fluoxetine have also been tested pharmacotherapy. There are few The package insert for sibutramine for weight loss but are not long-term studies that evaluate the states that because substantial approved for use in the treatment safety or efficacy of most currently increases in blood pressure occur of obesity. Mazindol, diethylpropi- approved weight loss medications. in some patients, regular monitor- on, phentermine, benzphetamine, At present, sibutramine and orlistat ing of blood pressure is required and phendimetrazine are approved are available for long-term use. when prescribing sibutramine. for only short-term use for the Based on their risk/benefit ratio, With orlistat, a possible decrease treatment of obesity. Herbal prepa- these drugs can be recommended

36 for use as an adjunct to diet and may be continued as long as it is Because adverse events may physical activity for patients with effective and the adverse effects increase with combination drug a BMI ≥ 30, without concomitant are manageable and not serious. therapy, it seems wise that, until obesity-related risk factors or There are no indications for speci- further safety data are available, diseases, and for patients with a fying how long a weight loss drug using weight loss drugs individu- BMI ≥ 27 who have concomitant should be continued. Therefore, an ally would be more prudent. Some obesity-related risk factors or dis- initial trial period of several weeks patients will respond to lower eases.59 Only patients who are at with a given drug may help deter- doses, so the full dosage is not increased medical risk because of mine its efficacy for a given always necessary. their weight should use weight loss patient. If a patient does not medications; they should not be respond to a drug with reasonable Drugs should be used only as part used for cosmetic weight loss. weight loss, the clinician should of a comprehensive program that reassess the patient to determine includes behavior therapy, diet, Not every patient responds to drug adherence to the medication regi- and physical activity. Appropriate therapy. Trials have shown that men and adjunctive therapies, or monitoring for side effects must initial responders tend to continue he/she should consider the need be continued while drugs are part to respond, whereas initial nonre- for adjustment of the dosage. If of the regimen. Patients will need sponders are less likely to respond, the patient continues to be unre- to return for followup visits in even with an increase in dosage.60,61 sponsive to the medication, or 2 to 4 weeks, then monthly for If a patient does not lose 2 kilo- serious adverse effects occur, the 3 months, then every 3 months for grams (4.4 lbs) in the first 4 weeks clinician should consider the first year after initiating the after initiating therapy, the likeli- discontinuing the treatment.64 medication. After the first year, the hood of long-term response is very doctor will advise the patient on low.61 This may be used to guide There is great interest in weight appropriate return visits. The pur- treatment by continuing medica- loss drugs among consumers. pose of these visits is to monitor tion for the responders or by dis- Because of the possibility of seri- weight, blood pressure, and pulse, continuing it for the nonrespon- ous adverse effects, it is incumbent discuss side effects, conduct labo- ders. If weight is lost within the upon the practitioner to use drug ratory tests, and answer the initial 6 months of therapy or if therapy with caution. Herbal med- patient’s questions. weight is maintained after the ini- ications are not recommended as tial weight loss phase, the drug part of a weight loss program. Since obesity is a chronic disease, may be continued. It is important These preparations have unpre- the short-term use of drugs is not to remember that the major role dictable amounts of active ingredi- helpful. The health professional of these medications is to help ents and unpredictable—and poten- should include drugs only in the patients comply with their diet tially harmful—effects. In those context of a long-term treatment and physical activity plans while patients with a lower risk of obesi- strategy.65 The risk/benefit ratio losing weight. Medications cannot ty, nonpharmacologic therapies are cannot be predicted at this time, be expected to continue to be the treatments of choice. It is since not enough long-term data effective in weight loss or weight important that the clinician monitor (> 1 year) are available on any of maintenance once the drug has the efficacy and side effects of the the available drugs. been stopped.62,63 The use of a drug drugs currently on the market.

37 Weight Loss Surgery

Figure 5 eight loss surgery is an Surgical Procedures in Current Use option for weight reduc- Wtion in patients with clinically severe obesity, i.e., a Vertical Banded Gastroplasty Roux-en-Y Gastric Bypass BMI ≥40, or a BMI ≥ 35 with comorbid conditions. Weight loss surgery should be reserved for patients in whom other methods of treatment have failed and who have clinically severe obesity (once commonly referred to as “morbid obesity”66). Weight loss surgery provides medically signifi- cant sustained weight loss for more than 5 years in most patients. Two types of operations have proven to be effective: those that cardiopulmonary failure may improvement in quality of life. restrict gastric volume (banded have mortality rates that range Late complications are uncom- gastroplasty) and those that, in from 2 to 4 percent. Operative mon, but some patients may devel- addition to limiting food intake, complications, including anasto- op incisional , gallstones, also alter digestion (Roux-en-Y motic leak, subphrenic abscess, and, less commonly, weight loss gastric bypass). See Figure 5. splenic injury, pulmonary failure and dumping syndrome. embolism, wound , and Patients who do not follow the Lifelong medical monitoring after stoma stenosis, occur in less than instructions to maintain an ade- 67 surgery is a necessity. Periopera- 10 percent of patients. quate intake of vitamins and min- tive complications vary with erals may develop deficiencies of weight and the overall health of An integrated program that pro- vitamin B12 and iron with the individual. In the published vides guidance on diet, physical anemia. Neurologic symptoms literature, young patients activity, and psychosocial con- may occur in unusual cases. without comorbidities with a cerns before and after surgery is Thus, surveillance should include BMI < 50 kg/m2 who have under- necessary. Most patients fare monitoring indices of inadequate gone surgery have mortality rates remarkably well with reversal of nutrition. Documentation of less than 1 percent, whereas diabetes, control of hypertension, improvement in preoperative massively obese patients with a marked improvement in mobility, comorbidities is beneficial and BMI > 60 kg/m2 who are also return of , cure of pseudo- advised. diabetic, hypertensive, and in tumor cerebri, and significant

38 Medical Evaluation, Treatment, and Monitoring of the Obese Patient on a Weight Loss Regimen— A Clinician’s Approach and Perspective

Pretreatment Evaluation , atherosclerotic car- and morning headaches also occur. A physical examination and rou- diovascular disease, osteoarthritis On exam, hypertension, narrowing tine laboratory evaluation should of the lower extremities, gallblad- of the upper airway, scleral injec- be performed on an obese patient der disease, , and cancers. tion, and leg edema, secondary to starting a weight loss regimen if In men, obesity is associated with pulmonary hypertension, may be this has not been done within the colorectal and prostate ; observed. Laboratory studies may past year. The medical history and in women, it is associated with show . If signs of physical exam should focus on endometrial, gallbladder, cervical, sleep apnea are present, referral to causes and complications of ovarian, and .3 Signs a pulmonologist, or sleep specialist, obesity. BMI should be calculated and symptoms of these disorders is appropriate. and waist circumference measured may have been overlooked by the to better assess risk and to offer patient and should be carefully Examine the thyroid and look for measures of outcome in addition reviewed by the practitioner. For manifestations of . to weight loss. Although the example, weight loss is frequently In addition, leg edema, , causes of obesity are not fully a symptom of the onset of type (coarse known, certain factors clearly play 2 diabetes. Some patients may pigmented skin that is a sign a role. Family history is important come to their initial visit, proud of ), and intert- because of the strong of their recent weight loss and riginous rashes with signs of skin of obesity; polycystic ovarian unaware of its significance. breakdown are commonly seen disease and hypothyroidism are in the very obese. known causes of overweight. The practitioner should also be The use of , lithi- alert to the possible presence of Laboratory Tests um, phenothiazines, glucocorti- , a disorder Baseline and diagnostic laboratory coids, progestational , that is often overlooked in obese tests may include assessment of cyproheptadine and perhaps other patients. Symptoms and signs electrolytes, function tests, antihistamines, , include very loud snoring or complete blood counts, total cho- insulin, and other medications is cessation of breathing during sleep, lesterol, HDL- and LDL-choles- associated with weight gain. which is often followed by a loud terol, triglycerides, and thyroid- In some cases, it may be possible clearing breath, then brief awaken- stimulating hormone, or full to change medications in favor ing. The patient may be a restless . A recent of those that do not promote sleeper; some find that they can baseline electrocardiogram should weight gain. sleep comfortably only in the sit- be available; if not, it should ting position. The patient’s partner be performed. Other laboratory The practitioner should search for may best describe these symptoms. studies should be performed on complications of obesity, such as Daytime , with episodes of the basis of findings from the hypertension, type 2 diabetes, sleepiness at inappropriate times, initial evaluation.

39 Frequent visits to weigh patients Demonstrating Medical and review their adherence to Improvement medication, diet, and exercise may be associated with better weight Before beginning treatment, loss. Such visits may be brief and results of the physical examination may be conducted by a nurse or and laboratory tests should be other staff person. shared with the patient. Emphasis should be placed on any new Routine Monitoring findings, particularly those associ- In general, healthy patients on ated with obesity that would be a weight loss regimen should be expected to improve with weight seen in the office within 2 to 4 loss. The patient should focus on weeks of starting treatment in improvements in these health para- order to monitor both the treat- meters, rather than focus on ment’s effectiveness and its side achieving an ideal body weight or effects. Visits approximately a similarly large weight loss that every 4 weeks are adequate may or may not be attainable. during the first 3 months if the Improvements in health complica- Lifestyle, Diet, and patient has a favorable weight tions should be discussed on an Physical Activity loss and few side effects. More ongoing basis. Many patients find If the patient is not seeing a frequent visits may be required this a helpful motivator because, registered or other based on clinical judgment, at some point, weight is likely to counselor, food and exercise particularly if the patient has stabilize at a level above their records should be reviewed medical complications. Blood own “ideal” weight. By focusing during office visits in order to pressure, pulse, and weight patients on the medical rather than assess compliance with the should be monitored each visit, the cosmetic benefits of weight prescribed dietary and exercise with waist circumference loss, you may better help them recommendations. A supportive, measured intermittently. Less to attain their goals. sympathetic approach (rather than frequent followup is required after a judgmental one) is recommend- the first 6 months. ed, as described on pages 30–33.

40 Weight Reduction After Age 65

here is a growing held from adult men and women status in older persons in the prevalence of obesity on the basis of age alone up to same manner as in younger adults. among older persons. 80 years of age. Weight loss requires proper nutri- Age alone should not tional and exercise counseling, preclude treatment for The higher prevalence of cardio- including resistance training and Tobesity in adult men and women. vascular risk factors in overweight moderate weight-bearing exercise. A clinical decision to forgo obesi- versus nonoverweight persons is However, the weight control ty treatment in an older adult clearly observed at older ages. In program must often be individually should be guided by an evaluation addition, obesity is a major predic- tailored to have a desirable outcome. of the potential benefits of weight tor of functional limitations and This would include preservation of reduction for day-to-day function- mobility impairments in older body cell mass and its function, ing and reduction of the risk of adults. Weight loss reduces risk and loss of fat mass.68-75 future cardiovascular events, as factors and improves functional well as the patient’s motivation for weight reduction. Being obese does not appear to benefit older persons. However, care must be taken to ensure that any weight reduction program minimizes the likelihood of adverse effects on bone health or other aspects of nutritional status. There is little evidence at present to indicate that obesity treatment should be with-

Obesity at older ages

Age alone should not preclude treatment for obesity. However, care must be taken to minimize the likelihood of adverse effects on bone health or other aspects of nutritional status.

41 References

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43 51. Katzel LI, Bleecker ER, Colman EG, 60. Weintraub M, Sundaresan PR, Madan 69. Galanos AN, Pieper CF, Coroni- Rogus EM, Sorkin JD, Goldberg AP. M, et al. Long-term weight control study. Huntley JC, et al. Nutrition and func- Effects of weight loss vs aerobic I (weeks 0 to 34). The enhancement of tion: is there a relationship between exercise training on risk factors for behavior modification, caloric restric- body mass index and the functional coronary disease in healthy, obese, tion, and exercise by fenfluramine plus capabilities of community-dwelling middle-aged and older men. A random- phentermine versus placebo. Clin elderly? J Am Geriatr Soc. ized controlled trial. JAMA. Pharmacol Ther. 1992;51:586-594. 1994;42:368-373. 1995;274:1915-1921. 61. Guy-Grand B, Apfelbaum M, Crepaldi 70. Launer LJ, Harris T, Rumpel C, et al. 52. Pate RR, Pratt M, Blair SN, et al. G, Gries A, Lefebvre P, Turner P. Body mass index, weight change, and Physical activity and public health. International trial of long-term dexfen- risk of mobility disability in middle- A recommendation from the Centers fluramine in obesity. Lancet. aged and older women. JAMA. for Disease Control and Prevention and 1989;2:1142-1145. 1994;271:1093-1098. the American College of Sports Medicine. JAMA. 1995;273:402-407. 62. Bray GA. Use and abuse of appetite- 71. Ensrud KE, Nevitt MC, Yunis C, et al. suppressant drugs in the treatment of Correlates of impaired function in older 53. NIH Consensus Conference. Physical obesity. Ann Intern Med. 1993;119: women. J Am Geriatr Soc.1994; activity and cardiovascular health. 707-713. 42:481-489. JAMA. 1996;276:241-246. 63. Galloway SM, Farquhar DL, Munro JF. 72. Coakley EH, Kawachi I, Manson JE, et 54. Wadden TA, Foster GD. Behavioral The current status of antiobesity drugs. al. Lower levels of physical functioning assessment and treatment of markedly Postgrad Med J. 1984;60 (Suppl 3): are associated with higher body weight obese patients. In: Wadden TA, 19-26. among middle-aged and older women. VanItallie TB, eds. Treatment of the Int J Obesity. 1998; 22:958-965. Seriously Obese Patient. New York: 64. Long-term pharmacotherapy in the Guilford Press; 1992:290-330. management of obesity. National Task 73. Visser M, Langlois J, Guralnik JM, et Force on the Prevention and Treatment al. High body fatness, but not low fat- 55. Connolly HM, Crary JL, McGoon MD, of Obesity. JAMA. 1996;276:1907- free mass, predicts disability in older et al. Valvular heart disease associated 1915. men and women: the Cardiovascular with fenfluramine-phentermine. N Engl Health Study. Am J Clin Nutr. J Med. 1997;337: 581-588. 65. Weintraub M, Bray GA. Drug treatment 1998;68:584-590. of obesity. Med Clin North Am. 56. Centers for Disease Control and 1989;73:237-249. 74. Visser M, Marris TB, Langlois J, et al. Prevention. Cardiac valvulopathy asso- Body fat and mass in ciated with exposure to fenfluramine or 66. Gastrointestinal surgery for severe obe- relation to physical disability in very dexfenfluramine: U.S. Department of sity. National Institutes of Health old men and women of the Framinghan Health and Human Services interim Consensus Development Conference Heart Study. J Gerontology. public health recommendation, Statement. Am J Clin Nutr. 1992; 1998;53A:M214-221. November 1997. MMWR Morb Mortal 55:615S-619S. Wkly Rep. 1997;46: 1061-1066. 75. Apovian CM, Frey CM, Rogers JZ, et 67. Pories WJ, Swanson MS, MacDonald al. Body mass index and physical func- 57. Methods for voluntary weight loss and KG, et al. Who would have thought it? tion in obese older women. J Am control. NIH Technology Assessment An operation proves to be the most Geriatr Soc. 1996;44:1487-1488. Conference Panel. Ann Intern Med. effective therapy for adult-onset dia- 1992;116:942-949. betes mellitus. Ann Surg. 76. Marcus B, Taylor E, Bock B, Simkin- 1995;222:339-350. Silverman L, Emmons K, Linnan L. 58. Bray GA, Ryan DH, Gordon D, Working healthy: Lifespan Employee Heidingsfelder S, Cerise F, Wilson K. 68. Hubert HB, Bloch DA, Fries JF. Risk Health Promotion Program (pamphlet). A double-blind randomized placebo- factors for physical disability in an Center for Behavioral and Preventive controlled trial of sibutramine. Obes aging cohort: the NHANES I Medicine, Miriam Hospital, Res. 1996;4:263-270. Epidemiologic Followup Study. J Providence, RI, 1995. Rheumatol. 1993;20:480-488. 59. Food and Drug Administration. Draft guidance clinical evaluation of weight control drug. Rockville, MD: FDA; 1996.

44 Introduction to the Appendices

In order to lose weight and maintain weight loss, your patients need to know what to do and be motivated to do it. These Appendices contain all the basic information they need to eat better, get in better condition, and improve health. You can help them to decide what’s best for them, and this is a good place to start. Appendix A. Body Mass Index Table

BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

Height Body Weight (pounds) (inches)

58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167 59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179 61 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185 62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 63 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197 64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210 66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216 67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223 68 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230 69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236 70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258 73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279 76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287

BMI 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

58 172 177 181 186 191 196 201 205 210 215 220 224 229 234 239 244 248 253 258 59 178 183 188 193 198 203 208 212 217 222 227 232 237 242 247 252 257 262 267 60 184 189 194 199 204 209 215 220 225 230 235 240 245 250 255 261 266 271 276 61 190 195 201 206 211 217 222 227 232 238 243 248 254 259 264 269 275 280 285 62 196 202 207 213 218 224 229 235 240 246 251 256 262 267 273 278 284 289 295 63 203 208 214 220 225 231 237 242 248 254 259 265 270 278 282 287 293 299 304 64 209 215 221 227 232 238 244 250 256 262 267 273 279 285 291 296 302 308 314 65 216 222 228 234 240 246 252 258 264 270 276 282 288 294 300 306 312 318 324 66 223 229 235 241 247 253 260 266 272 278 284 291 297 303 309 315 322 328 334 67 230 236 242 249 255 261 268 274 280 287 293 299 306 312 319 325 331 338 344 68 236 243 249 256 262 269 276 282 289 295 302 308 315 322 328 335 341 348 354 69 243 250 257 263 270 277 284 291 297 304 311 318 324 331 338 345 351 358 365 70 250 257 264 271 278 285 292 299 306 313 320 327 334 341 348 355 362 369 376 71 257 265 272 279 286 293 301 308 315 322 329 338 343 351 358 365 372 379 386 72 265 272 279 287 294 302 309 316 324 331 338 346 353 361 368 375 383 390 397 73 272 280 288 295 302 310 318 325 333 340 348 355 363 371 378 386 393 401 408 74 280 287 295 303 311 319 326 334 342 350 358 365 373 381 389 396 404 412 420 75 287 295 303 311 319 327 335 343 351 359 367 375 383 391 399 407 415 423 431 76 295 304 312 320 328 336 344 353 361 369 377 385 394 402 410 418 426 435 443

46 Appendix B. Shopping—What To Look For

Foods Lower in Calories and Fat one that is lowest in calories and fat. Below is a label that identifies important information. Use this guide to help you shop for foods that are To achieve your weight goal, you may need to eat nutritious and lower in calories and fat to help you much less than this reference amount. For achieve your weight goal. Learning how to read a example, if you eat 1,600 calories per day, your Nutrition Facts food label will help you save time total daily fat limit should be 53 grams (30 percent in the store and fill your kitchen with low calorie calories from fat) and 18 grams of foods. (10 percent calories from fat). If you eat 1,200 Read labels as you shop. Pay attention to the calories per day, your total daily fat limit should be and the servings per container. All 40 grams (30 percent calories from fat), and your labels list total calories and fat in a serving size of total daily saturated fat limit would be 13 grams the product. Compare the total calories in the (10 percent calories from fat). product you choose with others like it; choose the

Product: Check for:

• Serving size • Number of servings

• Calories • Total fat in grams • Saturated fat in grams • Cholesterol in milligrams • Sodium in milligrams

Here, the label gives the amounts for the different nutrients in one serving. Use it to help you keep track of how many calories and how much fat, saturated fat, cholesterol, and sodium you are getting from different foods.

The “% Daily Value” shows you how much of the recommended amounts the food provides in one serving, if you eat 2,000 calories a day. For example, one serving • of this food gives you 18 percent of your total fat • recommendation. Here you can see the recommended daily amount for each nutrient for two calorie levels. If you eat a 2,000 calorie diet, you should be eating less than 65 grams of fat and less than 20 grams of saturated fat. If you eat 2,500 calories a day, you should eat less than 80 grams of fat and 25 grams of saturated fat. Your daily amounts may be higher or lower, depending on the calories you eat.

47 Shopping—What To Look For continued

Fat Matters, but Calories Count weight loss. This is especially true when you eat more of the reduced fat food than you would of the is a calorie whether it comes regular item. For example, if you eat twice as from fat or carbohydrate. Anything eaten in excess many fat free cookies, you have actually increased can lead to weight gain. You can lose weight by your overall calorie intake. eating less calories and by increasing your The following list of foods and their reduced fat physical activity. Reducing the amount of fat and varieties will show you that just because a product saturated fat that you eat is one easy way to limit is fat free, it doesn’t mean that it is “calorie free.” your overall calorie intake. However, eating fat And, calories do count! free or reduced fat foods isn’t always the answer to

Fat Free or Reduced Fat Regular

Calories Calories

Reduced fat peanut butter, 187 Regular peanut butter, 191 2 T 2 T

Cookies: Cookies: Reduced fat chip cookies, 118 Regular chocolate chip cookies, 142 3 cookies (30 g) 3 cookies (30 g)

Fat free fig cookies, 102 Regular fig cookies, 111 2 cookies (30 g) 2 cookies (30 g)

Ice cream: Ice cream: Nonfat vanilla frozen (< 1% fat), 100 Regular whole milk vanilla 104 1 1 /2 cup frozen yogurt (3–4% fat), /2 cup

Light vanilla ice cream (7% fat), 111 Regular vanilla ice cream (11% fat), 133 1 1 /2 cup /2 cup

Fat free caramel topping, 103 Caramel topping, homemade with butter 103 2 T 2 T

Lowfat granola cereal, 213 Regular granola cereal, 257 1 1 approx. /2 cup (55 g) approx. /2 cup (55 g)

Lowfat blueberry muffin, 131 Regular blueberry muffin, 138 1 1 1 small (2 /2 inch) 1 small (2 /2 inch)

Baked tortilla chips, 113 Regular tortilla chips, 143 1 oz. 1 oz.

Lowfat cereal bar, 130 Regular cereal bar, 140 1 bar (1.3 oz.) 1 bar (1.3 oz.)

Nutrient data taken from Nutrient Data System for Research, Version v4.02/30, Nutrition Coordinating Center, University of Minnesota.

48 Appendix C. Low Calorie, Lower Fat Alternatives

These low calorie alternatives provide new ideas This guide is not meant to be an exhaustive list. for old favorites. When making a , We stress reading labels to find out just how many remember to consider vitamins and minerals. calories are in the specific products you decide to Some foods provide most of their calories from buy. and fat but give you few, if any, vitamins and minerals.

Instead of… Replace with…

• Evaporated whole milk • Evaporated fat free (skim) or reduced fat (2%) milk • Whole milk • Lowfat (1%), reduced fat (2%), or fat free (skim) milk • Ice cream • Sorbet, sherbet, lowfat or fat free frozen yogurt, or ice milk (check label for calorie content) • Whipping cream • Imitation whipped cream (made with fat free [skim] milk) or lowfat vanilla yogurt • Sour cream • Plain lowfat yogurt • Cream cheese • Neufchatel or “light” cream cheese or fat free cream cheese • Cheese (cheddar, Swiss, jack) • Reduced calorie cheese, low calorie processed cheeses, etc. • Fat free cheese

• American cheeseDairy Products • Fat free American cheese or other types of fat free cheeses • Regular (4%) cottage cheese • Lowfat (1%) or reduced fat (2%) cottage cheese • Whole milk mozzarella cheese • Part skim milk, low-moisture mozzarella cheese • Whole milk ricotta cheese • Part skim milk ricotta cheese • Coffee cream (half and half) or nondairy creamer • Lowfat (1%) or reduced fat (2%) milk or nonfat (liquid, powder) dry milk powder

• Ramen noodles • Rice or noodles (spaghetti, macaroni, etc.) • Pasta with white sauce (alfredo) • Pasta with red sauce (marinara) • Pasta with cheese sauce • Pasta with vegetables (primavera) • Granola • Bran flakes, crispy rice, etc. • Cooked grits or oatmeal

and Pasta • Whole grains (e.g., couscous, barley, bulgur, etc.) • Reduced fat granola Cereals, Grains,

• Cold cuts or lunch meats • Lowfat cold cuts (95% to 97% fat free lunch meats, (bologna, salami, liverwurst, etc.) lowfat pressed meats) • Hot dogs (regular) • Lower fat hot dogs • Bacon or sausage • Canadian bacon or lean ham • Regular ground beef • Extra lean ground beef such as ground round or ground (read labels) and Poultry • Chicken or turkey with skin, duck, or gooseMeat, Fish, • Chicken or turkey without skin (white meat) • Oil-packed tuna • Water-packed tuna (rinse to reduce sodium content)

49 Low Calorie, Lower Fat Alternatives continued

Instead of… Replace with…

• Beef (chuck, rib, brisket) • Beef (round, loin) (trimmed of external fat) (choose select grades) • Pork (spareribs, untrimmed loin) • Pork tenderloin or trimmed, lean smoked ham • Frozen breaded fish or fried fish • Fish or shellfish, unbreaded (fresh, frozen, canned (homemade or commercial) in water) • Whole eggs • Egg whites or egg substitutes • Frozen TV dinners (containing more than • Frozen TV dinners (containing less than

13 grams of fat per serving)Meat, Fish, 13 grams of fat per serving and lower in sodium) • Chorizo sausage • Turkey sausage, drained well (read label)

and Poultry (continued) • Vegetarian sausage (made with )

• Croissants, brioches, etc. • Hard french rolls or soft “brown ’n serve” rolls • Donuts, sweet rolls, muffins, scones, or pastries • English muffins, bagels, reduced fat or fat free muffins or scones • Party crackers • Lowfat crackers (choose lower in sodium) • Saltine or soda crackers (choose lower in sodium) • Cake (pound, chocolate, yellow) • Cake (angel food, white, gingerbread)

• CookiesBaked Goods • Reduced fat or fat free cookies (graham crackers, ginger snaps, fig bars) (compare calorie level)

• Nuts • Popcorn (air-popped or light microwave), fruits, vegetables • Ice cream, e.g., cones or bars • Frozen yogurt, frozen fruit, or chocolate pudding bars Sweets

• Custards or puddings (made with whole milk)Snacks and • Puddings (made with skim milk)

• Regular margarine or butter • Light-spread margarines, diet margarine, or whipped butter, tub or squeeze bottle • Regular mayonnaise • Light or diet mayonnaise or mustard • Regular salad dressings • Reduced calorie or fat free salad dressings, lemon juice, or plain, herb-flavored, or wine vinegar • Butter or margarine on toast or bread • Jelly, jam, or honey on bread or toast • Oils, shortening, or lard • Nonstick cooking spray for stir-frying or sautéing Fats, Oils, and

Salad Dressings • As a substitute for oil or butter, use applesauce or prune puree in baked goods

• Canned cream soups • Canned broth-based soups • Canned beans and franks • Canned baked beans in tomato sauce • Gravy (homemade with fat and/or milk) • Gravy mixes made with water or homemade with the fat skimmed off and fat free milk included • Fudge sauce • Chocolate syrup • Avocado on sandwiches • Cucumber slices or lettuce leaves

• Guacamole dip or refried beans with lardMiscellaneous • Salsa

50 Appendix D. Sample Reduced Calorie Menus

Traditional American Cuisine—1,200 Calories You can use the exchange list in Appendix E to give yourself more choices. Calories Fat % Fat Exchange for: Breakfast (grams) • Whole wheat bread, 1 medium slice 70 1.2 15 (1 bread/starch) 1 • Jelly, regular, 2 tsp 30 0 0 ( /2 fruit) 1 • Cereal, shredded wheat, /2 cup 104 1 4 (1 bread/starch) • Milk, 1%, 1 cup 102 3 23 (1 milk) 3 1 • Orange juice, /4 cup 78 0 0 (1 /2 fruit) • Coffee, regular, 1 cup 5 0 0 (free) Breakfast total 389 5.2 10

Lunch • Roast beef sandwich: Whole wheat bread, 2 medium slices 139 2.4 15 (2 bread/starch) Lean roast beef, unseasoned, 2 oz 60 1.5 23 (2 lean protein) Lettuce, 1 leaf 1 0 0 Tomato, 3 medium slices 10 0 0 (1 vegetable) 1 Mayonnaise, low calorie, 1 tsp 15 1.7 96 ( /3 fat) • Apple, 1 medium 80 0 0 (1 fruit) • Water, 1 cup 0 0 0 (free) Lunch total 305 5.6 16

Dinner • Salmon, 2 ounces edible 103 5 44 (2 lean protein) 1 1 • Vegetable oil, 1 /2 tsp 60 7 100 (1 /2 fat) 3 • Baked potato, /4 medium 100 0 0 (1 bread/starch) • Margarine, 1 tsp 34 4 100 (1 fat) 1 1 • Green beans, seasoned, with margarine, /2 cup 52 2 4 (1 vegetable) ( /2 fat) • Carrots, seasoned 35 0 0 (1 vegetable) • White dinner roll, 1 small 70 2 28 (1 bread/starch) • Iced tea, unsweetened, 1 cup 0 0 0 (free) • Water, 2 cups 0 0 0 (free) Dinner total 454 20 39

Snack 1 • Popcorn, 2 /2 cups 69 0 0 (1 bread/starch) 3 3 • Margarine, /4 tsp 30 3 100 ( /4 fat)

Total 1,247 34–36 24–26

Calories ...... 1,247 Saturated fat, % kcals...... 7 Total carbohydrate, % kcals ...... 58 Cholesterol, mg ...... 96 Total fat, % kcals...... 26 Protein, % kcals ...... 19 *Sodium, mg ...... 1,043 Note: Calories have been rounded.

1,200: 100% RDA met for all nutrients except vitamin E 80%, vitamin B2 96%, 94%, calcium 68%, iron 63%, and zinc 73%. * No salt added in recipe preparation or as seasoning. Consume at least 32 ounces of water.

51 Sample Reduced Calorie Menus continued

Traditional American Cuisine—1,600 Calories You can use the exchange list in Appendix E to give yourself more choices. Calories Fat % Fat Exchange for: Breakfast (grams) • Whole wheat bread, 1 medium slice 70 1.2 15.4 (1 bread/starch) 1 • Jelly, regular, 2 tsp 30 0 0 ( /2 fruit) • Cereal, shredded wheat, 1 cup 207 2 8 (2 bread/starch) • Milk, 1%, 1 cup 102 3 23 (1 milk) 3 1 • Orange juice, /4 cup 78 0 0 (1 /2 fruit) • Coffee, regular, 1 cup 5 0 0 (free) 1 • Milk, 1%, 1 oz 10 0.3 27 ( /8 milk) Breakfast total 502 6.5 10

Lunch • Roast beef sandwich: Whole wheat bread, 2 medium slices 139 2.4 15 (2 bread/starch) Lean roast beef, unseasoned, 2 oz 60 1.5 23 (2 lean protein) American cheese, lowfat and low sodium, 3 1 slice, /4 oz 46 1.8 36 (1 lean protein) Lettuce, 1 leaf 1 0 0 Tomato, 3 medium slices 10 0 0 (1 vegetable) 2 Mayonnaise, low calorie, 2 tsp 30 3.3 99 ( /3 fat) • Apple, 1 medium 80 0 0 (1 fruit) • Water, 1 cup 0 0 0 (free) Lunch total 366 9 22

Dinner • Salmon, 3 ounces edible 155 7 40 (3 lean protein) 1 1 • Vegetable oil, 1 /2 tsp 60 7 100 (1 /2 fat) 3 • Baked potato, /4 medium 100 0 0 (1 bread/starch) • Margarine, 1 tsp 34 4 100 (1 fat) 1 1 • Green beans, seasoned, with margarine, /2 cup 52 2 4 (1 vegetable) ( /2 fat) 1 1 • Carrots, seasoned, with margarine, /2 cup 52 2 4 (1 vegetable) ( /2 fat) • White dinner roll, 1 medium 80 3 33 (1 bread/starch) 1 1 • Ice milk, /2 cup 92 3 28 (1 bread/starch) ( /2 fat) • Iced tea, unsweetened, 1 cup 0 0 0 (free) • Water, 2 cups 0 0 0 (free) Dinner total 625 28 38

Snack 1 • Popcorn, 2 /2 cups 69 0 0 (1 bread/starch) 1 1 • Margarine, /2 tsp 58 6.5 100 (1 /2 fat)

Total 1,613 50 28

Calories ...... 1,613 Saturated fat, % kcals ...... 8 Note: Calories have been rounded. Total carbohydrate, % kcals ...... 55 Cholesterol, mg ...... 142 1,600: 100% RDA met for all nutrients except vitamin E 99%, Total fat, % kcals ...... 29 Protein, % kcals ...... 19 iron 73%, and zinc 91%. *Sodium, mg ...... 1,341 * No salt added in recipe preparation or as seasoning. Consume at least 32 ounces of water. 52 Sample Reduced Calorie Menus continued

Asian American Cuisine—Reduced Calorie

Breakfast 1,600 Calories 1,200 Calories • Banana 1 small 1 small • Whole wheat bread 2 slices 1 slice • Margarine 1 tsp 1 tsp 3 3 • Orange juice /4 cup /4 cup 3 3 • Milk 1%, lowfat /4 cup /4 cup

Lunch 1 1 • Beef noodle soup, canned, low sodium /2 cup /2 cup • Chinese noodle and beef salad: Roast beef 3 oz 2 oz 1 Peanut oil 1 /2 tsp 1 tsp Soy sauce, low sodium 1 tsp 1 tsp 1 1 Carrots /2 cup /2 cup 1 1 Zucchini /2 cup /2 cup 1 1 Onion /4 cup /4 cup 1 1 Chinese noodles, soft type /4 cup /4 cup • Apple 1 medium 1 medium • Tea, unsweetened 1 cup 1 cup

Dinner • Pork stir-fry with vegetables: Pork cutlet 2 oz 2 oz Peanut oil 1 tsp 1 tsp Soy sauce, low sodium 1 tsp 1 tsp 1 1 Broccoli /2 cup /2 cup 1 Carrots 1 cup /2 cup 1 1 Mushrooms /4 cup /2 cup 1 • Steamed white rice 1 cup /2 cup • Tea, unsweetened 1 cup 1 cup

Snack • Almond cookies 2 cookies — 3 3 • Milk 1%, lowfat /4 cup /4 cup

Calories ...... 1,609 Calories ...... 1,220 Total carbohydrate, % kcals . . .56 Total carbohydrate, % kcals . . .55 Total fat, % kcals ...... 27 Total fat, % kcals ...... 27 *Sodium, mg ...... 1,296 *Sodium, mg ...... 1,043 Saturated fat, % kcals ...... 8 Saturated fat, % kcals ...... 8 Cholesterol, mg ...... 148 Cholesterol, mg ...... 117 Protein, % kcals ...... 20 Protein, % kcals ...... 21

1,600: 100% RDA met for all nutrients except zinc 95%, iron 87%, and calcium 93%. 1,200: 100% RDA met for all nutrients except vitamin E 75%, calcium 84%, magnesium 98%, iron 66%, and zinc 77%. * No salt added in recipe preparation or as seasoning. Consume at least 32 ounces of water.

53 Sample Reduced Calorie Menus continued

Southern Cuisine—Reduced Calorie

Breakfast 1,600 Calories 1,200 Calories 1 1 • Oatmeal, prepared with 1% milk, lowfat /2 cup /2 cup 1 1 • Milk, 1%, lowfat /2 cup /2 cup • English muffin 1 medium — • Cream cheese, light, 18% fat 1 T — 3 1 • Orange juice /4 cup /2 cup • Coffee 1 cup 1 cup • Milk, 1%, lowfat 1 oz 1 oz

Lunch • Baked chicken, without skin 2 oz 2 oz 1 • Vegetable oil 1 tsp /2 tsp • Salad: 1 1 Lettuce /2 cup /2 cup 1 1 Tomato /2 cup /2 cup 1 1 Cucumber /2 cup /2 cup • Oil and vinegar dressing 2 tsp 1 tsp 1 1 • White rice /2 cup /4 cup 1 1 • Margarine, diet /2 tsp /2 tsp 1 • Baking powder biscuit, prepared with vegetable oil 1 small /2 small • Margarine 1 tsp 1 tsp • Water 1 cup 1 cup

Dinner • Lean roast beef 3 oz 2 oz 1 1 • Onion /4 cup /4 cup • Beef gravy, water-based 1 T 1 T 1 1 • Turnip greens /2 cup /2 cup 1 1 • Margarine, diet /2 tsp /2 tsp • Sweet potato, baked 1 small 1 small 1 1 • Margarine, diet /2 tsp /4 tsp • Ground cinnamon 1 tsp 1 tsp • Brown sugar 1 tsp 1 tsp 1 1 • Corn bread prepared with margarine, diet /2 medium slice /2 medium slice 1 1 • Honeydew melon /4 medium /8 medium • Iced tea, sweetened with sugar 1 cup 1 cup

Snack • Saltine crackers, unsalted tops 4 crackers 4 crackers • Mozzarella cheese, part skim, low sodium 1 oz 1 oz

1,600: 100% RDA met for all nutrients except vitamin E 97%, Calories ...... 1,653 Calories ...... 1,225 magnesium 98%, iron 78%, and zinc 90%. Total carbohydrate, % kcals . . .53 Total carbohydrate, % kcals . . .50 1,200: 100% RDA met for all nutrients except vitamin E 82%, Total fat, % kcals ...... 28 Total fat, % kcals ...... 31

vitamin B1 & B2 95%, vitamin B3 99%, vitamin B6 88%, *Sodium, mg ...... 1,231 *Sodium, mg ...... 867 magnesium 83%, iron 56%, and zinc 70%. Saturated fat, % kcals ...... 8 Saturated fat, % kcals ...... 9 * No salt added in recipe preparation or as seasoning. Cholesterol, mg ...... 172 Cholesterol, mg ...... 142 Consume at least 32 ounces of water. Protein, % kcals ...... 20 Protein, % kcals ...... 21

54 Sample Reduced Calorie Menus continued

Mexican American Cuisine—Reduced Calorie

Breakfast 1,600 Calories 1,200 Calories 1 • Cantaloupe 1 cup /2 cup 1 1 • Farina, prepared with 1% lowfat milk /2 cup /2 cup • White bread 1 slice 1 slice • Margarine 1 tsp 1 tsp • Jelly 1 tsp 1 tsp 1 3 • Orange juice 1 /2 cup /4 cup 1 1 • Milk, 1%, lowfat /2 cup /2 cup

Lunch • Beef enchilada: Tortilla, corn 2 tortillas 2 tortillas 1 Lean roast beef 2 /2 oz 2 oz 2 2 Vegetable oil /3 tsp /3 tsp Onion 1 T 1 T Tomato 4 T 4 T 1 1 Lettuce /2 cup /2 cup Chili peppers 2 tsp 2 tsp 1 1 Refried beans, prepared with vegetable oil /4 cup /4 cup • Carrots 5 sticks 5 sticks • 6 sticks 6 sticks 1 • Milk, 1%, lowfat /2 cup — • Water — 1 cup

Dinner • Chicken taco: Tortilla, corn 1 tortilla 1 tortilla Chicken breast, without skin 2 oz 1 oz 2 2 Vegetable oil /3 tsp /3 tsp 1 Cheddar cheese, lowfat and low sodium 1 oz /2 oz Guacamole 2 T 1 T Salsa 1 T 1 T 1 1 • Corn, seasoned with /2 cup /2 cup 1 Margarine /2 tsp — 1 1 • Spanish rice without meat /2 cup /2 cup 1 • Banana 1 large /2 large 1 • Coffee 1 cup /2 cup • Milk, 1% 1 oz 1 oz

1,600: 100% RDA met for all nutrients except vitamin E 97% Calories ...... 1,638 Calories ...... 1,239 and zinc 84%. Total carbohydrate, % kcals . . .56 Total carbohydrate, % kcals . . .58 1,200: 100% RDA met for all nutrients except vitamin E 71%, Total fat, % kcals ...... 27 Total fat, % kcals ...... 26

vitamin B1 & B3 91%, vitamin B2 & iron 90%, and calcium 92%. *Sodium, mg ...... 1,616 *Sodium, mg ...... 1,364 * No salt added in recipe preparation or as seasoning. Saturated fat, % kcals ...... 9 Saturated fat, % kcals ...... 8 Consume at least 32 ounces of water. Cholesterol, mg ...... 143 Cholesterol, mg ...... 91 Protein, % kcals ...... 20 Protein, % kcals ...... 19

55 Sample Reduced Calorie Menus continued

Lacto-Ovo Vegetarian Cuisine—Reduced Calorie

Breakfast 1,600 Calories 1,200 Calories • Orange 1 medium 1 medium • Pancakes, made with 1% lowfat milk and eggs whites 3 4” circles 2 4” circles • Pancake syrup 2 T 1 T 1 1 • Margarine, diet 1 /2 tsp 1 /2 tsp 1 • Milk, 1%, lowfat 1 cup /2 cup • Coffee 1 cup 1 cup • Milk, 1%, lowfat 1 oz 1 oz

Lunch 1 • Vegetable soup, canned, low sodium 1 cup /2 cup 1 • Bagel 1 medium /2 medium 3 — • Processed american cheese, lowfat /4 oz • Spinach salad: Spinach 1 cup 1 cup 1 1 Mushrooms /2 cup /2 cup • Salad dressing, regular calorie 2 tsp 2 tsp • Apple 1 medium 1 medium • Iced tea, unsweetened 1 cup 1 cup

Dinner • Omelette: Egg whites 4 large eggs 4 large eggs Green pepper 2 T 2 T Onion 2 T 2 T 1 Mozzarella cheese, made from part 1 oz /2 oz skim milk, low sodium 1 Vegetable oil 1 T /2 T 1 1 • Brown rice, seasoned with /2 cup /2 cup 1 1 Margarine, diet /2 tsp /2 tsp 1 1 • Carrots, seasoned with /2 cup /2 cup 1 1 Margarine, diet /2 tsp /2 tsp • Whole wheat bread 1slice 1slice • Margarine, diet 1tsp 1tsp • Fig bar cookie 1bar 1bar • Tea 1 cup 1 cup • Honey 1 tsp 1 tsp 3 3 • Milk, 1%, lowfat /4 cup /4 cup

1,600: 100% RDA met for all nutrients except vitamin E 92%, Calories ...... 1,650 Calories ...... 1,205

vitamin B3 97%, vitamin B6 67%, iron 73%, and zinc 68%. Total carbohydrate, % kcals . . .56 Total carbohydrate, % kcals . . .60 1,200: 100% RDA met for all nutrients except vitamin E 75%, vitamin B1 Total fat, % kcals ...... 27 Total fat, % kcals ...... 25 92%, vitamin B3 69%, vitamin B6 59%, iron 54%, and zinc 46%. *Sodium, mg ...... 1,829 *Sodium, mg ...... 1,335 * No salt added in recipe preparation or as seasoning. Saturated fat, % kcals ...... 8 Saturated fat, % kcals ...... 7 Consume at least 32 ounces of water. Cholesterol, mg ...... 82 Cholesterol, mg ...... 44 Protein, % kcals ...... 19 Protein, % kcals ...... 18

56 Appendix E. Food Exchange List

Within each group, these foods can be exchanged for each other. You can use this list to give yourself more choices.

Vegetables contain 25 calories and 5 grams of Fruits contain 15 grams of carbohydrates and carbohydrate. One serving equals: 60 calories. One serving equals:

1 • /2 cup Cooked vegetables (carrots, • 1 small Apple, banana, orange, nectarine broccoli, zucchini, • 1 medium Fresh peach cabbage, etc.) • 1 Kiwi

• 1 cup Raw vegetables or 1 • /2 Grapefruit salad greens 1 1 • /2 Mango • /2 cup Vegetable juice • 1 cup Fresh berries (strawberries, If you’re hungry, eat more fresh or steamed raspberries, or blueberries) vegetables. • 1 cup Fresh melon cubes

1 • /8 Honeydew melon Fat Free and Very Low Fat Milk contains • 4 oz Unsweetened juice 90 calories and 12 grams of carbohydrate per serving. One serving equals: • 4 tsp Jelly or jam • 8 oz Milk, fat free or 1% fat

3 Lean Protein choices have 55 calories and • /4 cup Yogurt, plain 2 to 3 grams of fat per serving. One serving equals: nonfat or lowfat • 1 oz Chicken—dark meat, skin removed • 1 cup Yogurt, • 1 oz Turkey—dark meat, skin removed artificially sweetened • 1 oz Salmon, swordfish, herring, catfish, trout Very Lean Protein choices have 35 calories and • 1 oz Lean beef (flank 1 gram of fat per serving. One serving equals: steak, London broil, tenderloin, roast beef)* • 1 oz Turkey breast or chicken breast, skin removed • 1 oz Veal, roast, or lean chop* • 1 oz Fish fillet (flounder, • 1 oz Lamb, roast, or lean chop* sole, scrod, cod, • 1 oz Pork, tenderloin, or fresh ham* haddock, halibut) • 1 oz Lowfat cheese (3 grams or less of • 1 oz Canned tuna in water fat per ounce) • 1 oz Shellfish (clams, lobster, scallop, • 1 oz Lowfat luncheon meats (with shrimp) 3 grams or less of fat per ounce)

3 1 • /4 cup Cottage cheese, nonfat or lowfat • /4 cup 4.5% cottage cheese • 2 each Egg whites • 2 medium Sardines

1 • /4 cup Egg substitute * Limit to 1 to 2 times per week. • 1 oz Fat free cheese

1 • /2 cup Beans—cooked (black beans, kidney, chickpeas, or lentils): count as 1 starch/bread and 1 very lean protein

57 Food Exchange List continued

1 Medium Fat Proteins have 75 calories and • /2 cup Pasta—cooked 1 5 grams of fat per serving. One serving equals: • /2 cup Bulgur—cooked

1 • 1 oz Beef (any prime cut), corned beef, • /2 cup Corn, sweet potato, or green peas ground beef ** • 3 oz Baked sweet or white potato

3 • 1 oz Pork chop • /4 oz Pretzels • 1 each Whole egg (medium) ** • 3 cups Popcorn, hot-air popped or • 1 oz Mozzarella cheese microwave (80-percent light)

1 • /4 cup Ricotta cheese • 4 oz Tofu (note that this is a Fats contain 45 calories and 5 grams of fat per heart-healthy choice) serving. One serving equals: ** Choose these very infrequently. • 1 tsp Oil (vegetable, corn, canola, olive, etc.) • 1 tsp Butter Starches contain 15 grams of carbohydrate and • 1 tsp Stick margarine 80 calories per serving. One serving equals: • 1 tsp Mayonnaise • 1 slice Bread (white, pumpernickel, • 1 T Reduced fat margarine or whole wheat, rye) mayonnaise • 2 slice Reduced calorie or “lite” bread • 1 T Salad dressing 1 • /4 (1 oz) Bagel (varies) • 1 T Cream cheese 1 • /2 English muffin • 2 T Lite cream cheese 1 • /2 Hamburger bun 1 • /8 Avocado 3 • /4 cup Cold cereal • 8 large Black olives 1 • /3 cup Rice, brown or white—cooked • 10 large Stuffed green olives 1 • /3 cup Barley or couscous—cooked • 1 slice Bacon 1 • /3 cup Legumes (dried beans, peas, or lentils)—cooked

Source: Based on the American Dietetic Association Exchange List

58 Appendix F. Food Preparation—What to Do

Low Calorie, Lowfat • Two tablespoons of regular clear Italian salad Cooking/Serving Methods dressing adds an extra 136 calories and 14 grams of fat. Reduced fat Italian dressing adds only 30 Cooking low calorie, lowfat dishes may not take a calories and 2 grams of fat. long time, but best intentions can be lost with the addition of butter or other added fats at the table. It is important to learn how certain ingredients can Try These Lowfat Flavorings—Added add unwanted calories and fat to lowfat dishes— During Preparation or at the Table: making them no longer lower in calories and lower in fat. The following list provides examples of • Herbs—oregano, basil, cilantro, lower fat cooking methods and tips on how to thyme, parsley, sage, or serve your lowfat dishes. rosemary • Spices—cinnamon, nutmeg, pepper, or paprika Lowfat Cooking Methods • Reduced fat or fat free salad These cooking methods tend to be lower in fat: dressing • Bake • Mustard •Broil • Catsup • Microwave • Fat free mayonnaise • Roast—for vegetables and/or chicken without • Fat free or reduced fat sour cream skin • Fat free or reduced fat yogurt • Steam • Reduced sodium soy sauce • Lightly stir-fry or sauté in cooking spray, small • Salsa amounts of vegetable oil, or • Lemon or lime juice reduced sodium broth • Vinegar • Grill seafood, chicken, or vegetables • Horseradish • Fresh ginger How To Save Calories and Fat • Sprinkled buttered flavoring (not made with Look at the following examples for how to save real butter) calories and fat when preparing • Red pepper flakes and serving foods. You might be surprised at • Sprinkle of parmesan how easy it is. cheese (stronger flavor than most cheese) • Two tablespoons of butter on a baked potato adds an extra 200 • Sodium free salt 1 calories and 22 grams of fat. However, /4 cup substitute salsa adds only 18 calories and no fat. • Jelly or fruit preserves on toast or bagels

59 Appendix G. Dining Out—How To Choose

General Tips for Healthy Dining Out Reading the Menu

Whether or not you’re trying to lose weight, you • Choose lower calorie, lowfat cooking methods. can eat healthfully when dining out or bringing in Look for terms such as “steamed in its own food, if you know how. The following tips will juice” (au jus), “garden fresh,” “broiled,” help you move toward healthier eating as you limit “baked,” “roasted,” “poached,” “tomato juice,” your calories, as well as fat, saturated fat, “dry boiled” (in wine or lemon juice), or cholesterol, and sodium, when eating out. “lightly sautéed.” • Be aware of foods high in calories, fat, and You Are the Customer saturated fat. Watch out for terms such as “butter sauce,” “fried,” “crispy,” “creamed,” • Ask for what you want. Most “in cream or cheese sauce,” “au gratin,” restaurants will honor your “au fromage,” “escalloped,” “parmesan,” requests. “hollandaise,” “bearnaise,” “marinated (in oil),” “stewed,” “basted,” “sautéed,” “stir-fried,” • Ask questions. Don’t be “casserole,” “hash,” “prime,” “pot pie,” and intimidated by the menu— “pastry crust.” your server will be able to tell you how foods are prepared or suggest substitutions on the menu. Specific Tips for Healthy Choices • If you wish to reduce portion sizes, try ordering appetizers as your main meal. Breakfast • Fresh fruit or small glass of citrus juice • General tips: Limiting your calories and fat can be easy as long as you know what to order. Try • bread, bagel, asking these questions when you call ahead or or English muffin with before you order. Ask the restaurant, whether jelly or honey they would, on request, do • Whole grain cereal with lowfat (1%) or nonfat the following: milk – Serve nonfat (skim) milk • Oatmeal with nonfat milk topped with fruit rather than whole milk or cream. • Omelet made with egg whites or egg substitute – Reveal the type of cooking • Multigrain pancakes without butter on top oil used. • Nonfat yogurt (Try adding cereal or fresh fruit.) – Trim visible fat off poultry or meat. – Leave all butter, gravy, or sauces off a side dish or entree. Beverages – Serve salad dressing on the side. • Water with lemon – Accommodate special requests if made in • Flavored sparkling water advance by telephone or in person. (noncaloric) Above all, don’t get discouraged. There are usually • Juice spritzer (half fruit juice and half sparkling several healthy choices to choose from at most water) restaurants. • Iced tea • Tomato juice (reduced sodium)

60 Dining Out—How To Choose continued

Bread • Beans, chickpeas, and kidney beans Most bread and bread sticks are low in calories • Skip the nonvegetable choices: deli meats, and low in fat. The calories add up when you add bacon, egg, cheese, croutons. butter, margarine, or olive oil to the bread. Also, eating a lot of bread in addition to your • Choose lower calorie, reduced fat, or fat free meal will fill you up with extra dressing, lemon juice, or vinegar. unwanted calories and not leave enough room for fruits and Side Dish vegetables. • Vegetables and starches (rice, potato, noodles) make good additions to meals Appetizers and can also be combined • Steamed seafood for a lower calorie alternative to higher • Shrimp* cocktail (Limit calorie entrees. cocktail sauce—it’s high in sodium.) • Ask for side dishes without butter or margarine. • Melons or fresh fruit • Ask for mustard, salsa, or lowfat yogurt instead of sour cream or butter. • Bean soups

• Salad with reduced fat dressing (Or add lemon Dessert/Coffee juice or vinegar.) • Fresh fruit * If you are on a cholesterol-lowering diet, eat • Nonfat frozen yogurt shrimp and other shellfish in moderation. • Sherbet or fruit sorbet (These are usually fat Entree free, but check the calorie content.) • Poultry, fish, shellfish, and vegetable dishes are • Try sharing a dessert. healthy choices. • Ask for lowfat milk for your coffee (instead of • Pasta with red sauce or with cream or half-and-half). vegetables (primavera) • Look for terms such as “baked,” “broiled,” “steamed,” “poached,” “lightly sauteed,” or “stir- fried.” • Ask for sauces and dressings on the side. • Limit the amount of butter, margarine, and salt you use at the table.

Salads/Salad Bars • Fresh greens, lettuce, and spinach • Fresh vegetables—tomato, mushroom, carrots, cucumber, peppers, onion, radishes, and broccoli

61 Appendix H. Guide to Physical Activity

An increase in physical activity is an important Your exercise can be done all at one time or part of your weight management program. Most intermittently over the course of the day. Initial weight loss occurs because of decreased caloric activities may be walking or swimming at a slow intake. Sustained physical activity is most helpful pace. You can start by walking slowly for 30 in the prevention of weight regain. In addition, minutes 3 days a week. Then build to 45 minutes physical activity helps to reduce cardiovascular of more intense walking at least 5 days a week. and diabetes risks beyond what With this regimen, you can burn 100 to 200 weight reduction alone can calories per day. All adults should set a long-term do. Start exercising goal to accumulate at least 30 minutes or more of slowly, and gradually moderate-intensity physical activity on most, increase the intensity. and preferably all, days of the week. This Trying too hard at regimen can be adapted to other forms of first can lead to physical activity, but walking is particularly injury. attractive because of its safety and accessi- bility. Also, try to change everyday activities; for example, take the stairs instead of the elevator. Reducing sedentary time is a good strategy to increase activity by undertaking frequent, less

Examples of Moderate Amounts of Physical Activity*

Common Chores Sporting Activities Less Washing and waxing a car for 45–60 minutes Playing volleyball for 45–60 minutes Vigorous, More Time† Washing windows or floors for 45–60 minutes Playing touch football for 45 minutes

3 Gardening for 30–45 minutes Walking 1 /4 miles in 35 minutes (20 min/mile) Wheeling self in wheelchair for 30–40 minutes Basketball (shooting baskets) for 30 minutes

1 Pushing a stroller 1 /2 miles in 30 minutes Bicycling 5 miles in 30 minutes Raking leaves for 30 minutes Dancing fast (social) for 30 minutes Walking 2 miles in 30 minutes (15 min/mile) Water aerobics for 30 minutes Shoveling snow for 15 minutes Swimming laps for 20 minutes Stairwalking for 15 minutes Basketball (playing a game) for 15–20 minutes More Jumping rope for 15 minutes Vigorous, Less Time 1 Running 1 /2 miles in 15 minutes (15 min/mile)

* A moderate amount of physical activity is roughly equivalent to physical activity that uses approximately 150 calories of energy per day, or 1,000 calories per week. † Some activities can be performed at various intensities; the suggested durations correspond to expected intensity of effort.

62 Guide to Physical Activity continued

strenuous activities.76 With time, you may be able • It’s hard to remember to exercise. to—and you may want to—engage in more Leave your sneakers near the door to strenuous activities. Competitive sports such as remind yourself to walk, bring a change tennis and volleyball can provide an enjoyable of clothes to work and head form of exercise, but you must take care to avoid straight for exercise on the way injury. home, or put a note on your calendar at work to remind yourself to exercise. In addition, Overcoming Obstacles to simply try to develop the habit of Regular Activity integrating more activity into your daily routine. Many people who are completely inactive cite various reasons for their inactivity. Gaining Health Benefits From Physical Activity

• I don’t have the time to exercise. It is much easier to control your weight when you Physical activity does take time, are active, and being active helps to prevent but only about 1 hour per week osteoporosis (bone loss) and heart disease and of vigorous activity can greatly helps in the treatment of diabetes. In addition, benefit your heart, lungs, physical activity helps to increase your confidence muscles, and weight. Consider and decrease your stress. It can also decrease the amount of time you spend sadness and improve depression. watching television. Many forms of physical activity, such as riding an exercise bicycle or Benefits of Regular Activity using hand weights, can be done while watching television. • Your weight is much easier to control when you are active. • Physical activity can be lots of fun. • I don’t like to exercise. • You can be with other people when you You have bad memories of are active. doing situps or running in high • You’ll feel better when you’re school, sweating, puffing, and physically active. panting. Now we know that • You’ll look better when you’re you can get plenty of gain physically active. without pain! Activities you • Physical activity is good for your heart. already do, such as gardening and walking, can improve your health, so • Physical activity is a great way to burn off just do more of the activities you like. steam and stress. • Physical activity helps you beat the blues. • I don’t have the energy to be more active. • You’ll feel more confident when Once you become a little more active, you should you are active. have more energy. As you progress, daily tasks • You’ll have more energy. will seem easier.

63 Guide to Physical Activity continued

Fitting Activity Into Your Schedule You can have fun and feel healthier by doing any of the following: • What time of day is best for you to exercise? Try walking before going to work or school, or • Walk or ride a bike in your maybe you prefer evenings. Even a few minutes of neighborhood. walking counts. Try to build up to accumulating 30 • Join a walking club at a mall minutes per day. You can walk whenever it is or at work. convenient for you, or you can take an aerobics • Play golf at a local club. class instead. Whatever works for you is fine. The • Join a dance class. important thing is that you try to be more active. There is no one right time of day to exercise. • Work in your garden. Try to think about the little things you can do to • Use local athletic facilities. add more activity to your daily life. For instance, • Join a hiking or biking club. take the stairs instead of the elevator at work, park • Join a softball team or other sports team with farther away from the entrance to the mall, or walk coworkers, friends, or family. instead of driving to work or to shopping. These • Chase your kids in the park. If you don’t have little things add up and are easy to fit into your kids, take your neighbor’s. The parents will schedule. appreciate the break, the neighbors will enjoy Some people want to be alone when they exercise, it, and you’ll benefit from getting more activity. whereas others prefer the company of a group or • Walk your dog. If you don’t have a dog, class. Again, whatever works for you is fine. pretend you do. • Take a walk during your lunch break.

• What activities have you enjoyed in the past? Why did you stop? How can you start them again? You may enjoy other Planning To Become More Active activities that are better suited to your current • Begin slowly. lifestyle. The key is to find one or two If you have not been active for years, do not start you really like. with a 3-mile walk! Pushing yourself too hard or Consider varying too fast will make you sore and discouraged. your activity to prevent boredom. • Set realistic goals, and plan to succeed. For example, set the goal of walking two times this week. Even if you walk for only 5 minutes each time, you will have met your goal. Next week, you might try to walk two times for 10 minutes each time. Being realistic helps you to feel good about yourself, and it helps you to keep up the good work. You may want to keep an activity log to track your progress.

64 Guide to Physical Activity continued

• Reward yourself for reaching your goals. Two Sample Activity Programs Each time you meet an exercise goal, give yourself There are many ways to begin an activity program. a treat to mark the occasion. Some ideas include Below are two examples—a walking program and the following: buy yourself new sports equipment, a jogging program. These activities are easy ways ask your spouse to take the kids for an hour, visit a for most people to get friend, spend more time on your favorite hobby, regular exercise because buy yourself flowers or a plant, enjoy a long hot they do not require special bath, or go to a movie or rent a video. facilities or equipment other than good, comfortable shoes. If you find a particular week’s • Be active the healthy way. pattern tiring, repeat it before Most healthy people can safely going on to the next pattern. You do start a program of moderate not have to complete the walking activity. Talk to your doctor program in 12 weeks or the jogging first if you have heart program in 15 weeks. trouble or experience pain or pressure in your chest, neck, A sample jogging program shoulder, or arm during or after exercise. If you are older than 40 and have not been active, Drink plenty of fluids while you are active. If the you should not begin with a program as strenuous weather is bad, have a backup plan. Do your as jogging. Begin with the walking program activity indoors. Use the proper equipment, such instead. After completing the walking program, as a bicycle helmet for safety, and wear you can start with week 3 of the jogging program comfortable shoes or sneakers for below. walking. If walking or jogging does not meet your needs, look for other exercise programs in pamphlets and books on and sports medicine. • How hard should you exercise? Check out the programs and facilities of your local For the beginner in a sedentary park and recreation department lifestyle, activity level can be very or community recreation light. This would include increasing standing centers. Many programs activities, doing special chores like room painting, have adapted facilities pushing a wheelchair, doing yard work, ironing, for the disabled and cooking, and playing a musical instrument. for seniors. The next level would be light activity such as slow walking (24 minutes per mile), garage work, carpentry, house cleaning, child care, golf, sailing, and recreational table tennis. The next level would be moderate activity such as walking at 15 minutes per mile, weeding and hoeing a garden, carrying a load, cycling, skiing, tennis, and dancing.

65 A sample walking program

Warmup Exercising Cool down Total time

Week 1

Session A Walk 5 min. Then walk Then walk more 15 min. briskly 5 min. slowly 5 min.

Session B Repeat above pattern

Session C Repeat above pattern

Continue with at least three exercise sessions during each week of the program.

Week 2 Walk 5 min. Walk briskly 7 min. Walk 5 min. 17 min. Week 3 Walk 5 min. Walk briskly 9 min. Walk 5 min. 19 min. Week 4 Walk 5 min. Walk briskly 11 min. Walk 5 min. 21 min. Week 5 Walk 5 min. Walk briskly 13 min. Walk 5 min. 23 min. Week 6 Walk 5 min. Walk briskly 15 min. Walk 5 min. 25 min. Week 7 Walk 5 min. Walk briskly 18 min. Walk 5 min. 28 min. Week 8 Walk 5 min. Walk briskly 20 min. Walk 5 min. 30 min. Week 9 Walk 5 min. Walk briskly 23 min. Walk 5 min. 33 min. Week 10 Walk 5 min. Walk briskly 26 min. Walk 5 min. 36 min. Week 11 Walk 5 min. Walk briskly 28 min. Walk 5 min. 38 min. Week 12 Walk 5 min. Walk briskly 30 min. Walk 5 min. 40 min. Week 13 on:

Gradually increase your brisk walking time to 30 to 60 minutes, three or four times a week. Remember that your goal is to get the benefits you are seeking and enjoy your activity.

Walking Tips

• Hold your head up, and keep your back straight. • Bend your elbows as you swing your arms. For additional information about physical • Take long, easy strides. activity, request the NHLBI booklet Exercise and Your Heart: A Guide to Physical Activity. 66 A sample jogging program

If you are older than 40 and have not been active, you should not begin with a program as strenuous as jogging. Begin with the walking program instead. After completing the walking program, you can start with week 3 of the jogging program below. Warmup Exercising Cool down Total time Week 1

Session A Walk 5 min., Then walk 10 min. Then walk more 20 min. then stretch and Try not to stop. slowly 3 min. and limber up stretch 2 min.

Session B Repeat above pattern Session C Repeat above pattern Continue with at least three exercise sessions during each week of the program.

Week 2 Walk 5 min., then Walk 5 min., jog 1 min., Walk 3 min., 22 min. stretch and limber up walk 5 min., jog 1 min. stretch 2 min.

Week 3 Walk 5 min., then Walk 5 min., jog 3 min., Walk 3 min., 26 min. stretch and limber up walk 5 min., jog 3 min. stretch 2 min.

Week 4 Walk 5 min., then Walk 4 min., jog 5 min., Walk 3 min., 28 min. stretch and limber up walk 4 min., jog 5 min. stretch 2 min.

Week 5 Walk 5 min., then Walk 4 min., jog 5 min., Walk 3 min., 28 min. stretch and limber up walk 4 min., jog 5 min. stretch 2 min.

Week 6 Walk 5 min., then Walk 4 min., jog 6 min., Walk 3 min., 30 min. stretch and limber up walk 4 min., jog 6 min. stretch 2 min.

Week 7 Walk 5 min., then Walk 4 min., jog 7 min., Walk 3 min., 32 min. stretch and limber up walk 4 min., jog 7 min. stretch 2 min.

Week 8 Walk 5 min., then Walk 4 min., jog 8 min., Walk 3 min., 34 min. stretch and limber up walk 4 min., jog 8 min. stretch 2 min.

Week 9 Walk 5 min., then Walk 4 min., jog 9 min., Walk 3 min., 36 min. stretch and limber up walk 4 min., jog 9 min. stretch 2 min.

Week 10 Walk 5 min., then Walk 4 min., jog 13 min. Walk 3 min., 27 min. stretch and limber up stretch 2 min.

Week 11 Walk 5 min., then Walk 4 min., jog 15 min. Walk 3 min., 29 min. stretch and limber up stretch 2 min.

Week 12 Walk 5 min., then Walk 4 min., jog 17 min. Walk 3 min., 31 min. stretch and limber up stretch 2 min.

Week 13 Walk 5 min., then Walk 2 min., jog slowly Walk 3 min., 31 min. stretch and limber up 2 min., jog 17 min. stretch 2 min.

Week 14 Walk 5 min., then Walk 1 min., jog slowly Walk 3 min., 31 min. stretch and limber up 3 min., jog 17 min. stretch 2 min.

Week 15 Walk 5 min., then Jog slowly 3 min., Walk 3 min., 30 min. stretch and limber up jog 17 min. stretch 2 min.

Week 16 on: Gradually increase your jogging time from 20 to 30 minutes (or more, up to 60 minutes), three or four times a week. Remember that your goal is to get the benefits you are seeking and enjoy your activity.

67 Appendix I. Guide to Behavior Change

Why Weight Is Important How To Lose Weight and Maintain It

Being overweight or obese can have a negative effect on your overall health. Set the Right Goals. Overweight and obesity are Setting the right goals is an important first step. risk factors for developing Did you know that the amount of weight loss health problems such as needed to improve health may be much less than high blood you want to lose to look thinner? If your provider cholesterol, high suggests an initial weight loss goal that seems too blood pressure, heavy for you, please understand that your health diabetes, gall- can be greatly improved by a loss of 5 percent to bladder disease, 10 percent of your starting weight. That doesn’t gynecologic disorders, , some mean you have to stop there, but it does mean that types of cancer, and even some lung an initial goal of 5 to 10 percent of your starting problems. weight is both realistic and valuable. People try to lose weight for a number of reasons. Most people who are trying to lose weight focus You may already have a health problem that you on one thing: weight loss. However, focusing on know about, such as high blood pressure, and want dietary and exercise changes that will lead to to lose weight to improve your health. Others may permanent weight loss is much more productive. be losing weight in order to help prevent health People who are successful at managing their problems. Still others simply want to lose weight weight set only two to three goals at a time. to look thinner. For whatever reason, your health care provider may have given you information to Effective goals help you lose weight. are: In some ways, weight is different from other • specific health problems since it is not something that is • realistic hidden, such as high blood cholesterol levels. Patients may have had experience with health care • forgiving (less providers who are insensitive about their weight. than perfect) They may have had encounters where they felt For example: blamed rather than helped. Please be assured that when your health care provider discusses your “Exercise more” is a weight, it’s because it is an important fine goal, but it’s not aspect of your overall health care. specific enough. Your provider also understands “Walk 5 miles every day” that weight management is a is specific and measurable, but is it achievable if long-term challenge you’re just starting out? influenced by “Walk 30 minutes every day” is more attainable, behavioral, emotional, but what happens if you’re held up at work one and physical factors. day and there’s a thunderstorm during your walking time on another day? “Walk 30 minutes, 5 days each week” is specific, achievable, and forgiving. A great goal!

68 Guide to Behavior Change continued

Nothing Succeeds Like Success. Balance Your (Food) Checkbook. Shaping is a technique where you set some Self-monitoring refers to observing and recording short-term goals that get you closer and closer some aspect of your behavior, such as calorie to the ultimate goal (e.g., reduce fat from intake, servings of fruits and vegetables eaten, and 40 percent of calories to 35 percent of calories, amount of physical activity, etc., or an outcome of and ultimately to 30 percent). It is based on the these behaviors, such as weight. Self-monitoring of concept that “nothing succeeds like success.” a behavior can be used at times when you’re not Shaping uses two sure of how you are doing and at times when you important behavioral want the behavior to improve. Self-monitoring of a principles: behavior usually moves you closer to the desired behavior. When you record your behavior, you • Continuous produce real-time records for you and your health goals that move care provider to discuss. For example, keeping a you ahead in record of your exercise can let you and your small steps to provider know quickly how you are doing. When reach a distant your record shows that your exercise is increasing, point. you’ll be encouraged to keep it up. Some • Continuous rewards to patients find that standard self- keep you motivated to make changes. monitoring forms make it easier, while others like their own recording Reward Success system. Use the form (But Not With Food). in Appendix K to help Rewards that you control you keep track of your can encourage daily diet and activity levels. achievement of your goals, especially ones that have been hard to reach. Regular monitoring of your weight is key to An effective reward is something that is desirable, keeping it off. Remember these four points if you timely, and dependent upon meeting your goal. are keeping a weight chart or graph: The rewards you choose may be material (e.g., a • One day’s diet and exercise routine won’t movie, music CD, or payment necessarily affect your weight the next day. Your toward buying a larger item) or weight will change quite a bit over the course of an act of self-kindness a few days because of fluctuations in water and (e.g., an afternoon off body fat. from work, a massage, or personal time). • Try to weigh yourself at a set time once or twice Frequent, small rewards per week. This can be when you first wake up earned for meeting smaller and before eating and drinking, after exercise, or goals are more effective right before dinner, etc. than bigger rewards, • Whatever time you choose, just make sure it is requiring a long, difficult effort. always the same time and use the same scale to help you keep the most accurate records. • It may also be helpful to create a graph of your weight as a visual reminder of how you’re doing, rather than just listing numbers.

69 Guide to Behavior Change continued

Avoid a Chain Reaction. Get the (Fullness) Message. Stimulus (cue) control involves learning what Changing the way you eat can social or environmental cues encourage undesired help you to eat less and not eating, and then changing those cues. For example, feel deprived. you may learn from your self-monitoring • Eating slowly will techniques or from sessions with your health care help you to feel provider that you’re more likely to overeat when satisfied when you’ve watching TV, when treats are on display by the eaten the right amount office coffee pot, or when around a certain friend. of food for you. It takes 15 or Ways to change the situation more minutes for your brain to get the include: message you’ve been fed. Slowing the • Separating the rate of eating can allow you to feel association of eating full sooner and, therefore, help you from the cue eat less. (Don’t eat while • Eating lots of vegetables and fruit watching and also starting a meal with a television.) broth-based soup can help you • Avoiding or feel fuller. eliminating • Using smaller plates helps to the cue moderate portions so they don’t (Leave the appear too small. coffee room immediately after • Drinking at least eight glasses of noncaloric pouring coffee.) beverages each day will help you to feel full, possibly eat less, and benefit you in other ways. • Changing the environment (Plan to meet this friend in a nonfood setting.) • Changing your eating schedule, or setting one, can be helpful, especially if you tend to skip or In general, visible and reachable food items often delay meals and overeat later. lead to unplanned eating.

70 Appendix J. Weight and Goal Record

PATIENT

WEIGHT TOTAL DATE WEIGHT CHANGE WEIGHT WAIST BMI PATIENT GOALS SET THIS VISIT THIS VISIT CHANGE

DIET

PHYSICAL ACTIVITY

BEHAVIOR

NOTES

DIET

PHYSICAL ACTIVITY

BEHAVIOR

NOTES

DIET

PHYSICAL ACTIVITY

BEHAVIOR

NOTES

DIET

PHYSICAL ACTIVITY

BEHAVIOR

NOTES

71 Weight and Goal Record continued

Weight Management Chart Chart Your Weight. minutes of activity up from there Write in your first weight on the using 5 minute intervals. Each day You can’t drive a car if you can’t third line from the top of the graph go up the line above that day until see where you are going. You can’t on the left side. List successive you are on the same horizontal line control your weight if you can’t see weights up and down from there, as your physical activity for that where it’s going. An important one pound per line. Each day go up day, and mark the spot with a dot. behavior change is to keep a visual the line above that day Connect the dots with a solid line. record of your weight, along until you are on the with your physical activity same horizontal line See Your Success. habits. Beginning now, as your weight that weigh yourself every day day, and mark the The beginning of a weight loss and record each day’s spot with a dot. program is when weight graphing weight and minutes of Connect the dots is most fun—a good time to start physical activity using with a solid line. the habit. Your graph will show ups the graph on the next and downs because of changes in page, as shown in the fluid balance and differences in example below. Weigh Chart Your fluid intake from day to day. yourself at the same Physical Activity. You will learn to understand these time under the same Do the same for physical variations and use the overall trend conditions every day. The activity. Write in 5 minutes to guide your weight control plan. bottom horizontal lines show the of physical activity on the first Post the graph near your scale or days of the month. The vertical line from the bottom of the graph on your refrigerator as a reminder lines on the left side will show a on the right side. List additional of your progress. range of your weights, while the vertical lines on the right side will show the minutes of physical activity.

Weigh yourself at the same time under the same conditions every day. The bottom horizontal lines show the days of the month. The vertical lines on the left side will show a range of your weights, while the vertical lines on the right side will show the minutes of physical activity.

Source: Adapted from the Weight Management Center, Medical University of South Carolina

72 73 Appendix K. Weekly Food and Activity Diary

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

______

Breakfast Lunch Dinner Activity Notes: ______Weekly Food and Activity DiaryWeekly of: Week

74 Appendix L. Additional Resources

The Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: Evidence Report was developed by the NHLBI Expert Panel and released in June 1998. In addition to the Evidence Report (NIH Publication # 4083), a number of professional and patient education resources based on the report are available from the NHLBI. These resources include the executive summary of the report (NIH Publication #55-892), evidence tables of data supporting the report, an electronic textbook, a slide kit, a BMI calculator including a Palm top application, a menu planner, highlights for patients, and this Practical Guide to the Identification, Evaluation and Treatment of Overweight and Obesity in Adults. These resources are available on the NHLBI’s Aim For a Healthy Weight Web page at www.nhlbi.nih.gov or by contacting the address below: In addition, the Clinical Guidelines Evidence Report was published in the September 1998 supplement of Obesity Research which can be obtained from the North American Association for the Study of Obesity (NAASO) at the following address:

National Heart, Lung, and Blood Institute North American Association Health Information Center for the Study of Obesity P.O. Box 30105 8630 Fenton Street, Suite 412 Bethesda, MD 20824-0105 Silver Spring, MD 20910 (301) 592-8573 (301) 563-6526 (301) 592-8563 fax (301) 587-2365 fax www.naaso.org www.nhlbi.nih.gov Online publications on blood pressure, overweight, cholesterol, heart disease, sleep disorders and asthma

Other materials available from the NHLBI include:

1. Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). NIH publication #3046. www.nhlbi.nih.gov.

2. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. NIH publication #4080. www.nhlbi.nih.gov.

3. Consensus Statement: Gastrointestinal Surgery for Severe Obesity. www.odp.od.nih.gov/consensus

75 Additional Resources continued

National Institute of Diabetes and American College of Office of Cancer Communications Digestive and Kidney Diseases Sports Medicine National Cancer Institute National Institutes of Health P.O. Box 1440 National Institutes of Health Building 31, Room 9A52 Indianapolis, IN 46206-1440 Building 31, Room 10A-24 31 Center Drive (317) 637-9200 31 Center Drive, MSC 2580 Bethesda, MD 20892-1818 (317) 634-7817 fax Bethesda, MD 20892-2580 (301) 496-5877 http://www.acsm.org 1-800-4-CANCER (301) 402-2125 fax (1-800-422-6237) http://www.niddk.nih.go/index.htm American Diabetes Association http://www.nci.nih.gov 1660 Duke Street The Weight-Control Alexandria, VA 22314 National Eating Disorders Information Network 1-800-DIABETES Organization National Institute of Diabetes and http://www.diabetes.org 6655 South Yale Avenue Digestive and Kidney Diseases Tulsa, OK 74136 National Institutes of Health American Society of Bariatric (918) 481-4044 1 Win Way Physicians (ASBP) (918) 481-4076 fax Bethesda, MD 20892-0001 5600 South Quebec Street, http://www.laureate.com/ (301) 570-2177 Suite 109A aboutned.html (301) 570-2186 fax Englewood, CO 80111 1-800-WIN-8098 (303) 770-2526, ext. 17 Eating Disorders Awareness and (membership information only) Prevention, Inc. National Diabetes Information (303) 779-4833 603 Stewart Street, Suite 803 Clearinghouse (NIDDK) (303) 779–4834 fax Seattle, WA 98101 1 Information Way http://www.asbp.org (206) 382-3587 Bethesda, MD 20892-3560 http://members.aol.com/edapinc/ (301) 654-3327 American Obesity Association home.html (301) 907-8906 fax 1250 24th Street, NW, Suite 300 Washington, DC 20037 American Anorexia/Bulimia American Society for 202-776-7711 Association, Inc. Bariatric Surgery (ASBS) 202-776-7712 fax 165 West 46th Street, #1108 140 Northwest 75th Drive, http://www.obesity.org New York, NY 10036 Suite C (212) 575-6200 Gainesville, FL 32607 American Cancer Society http://members.aol.com/amanbu/ (352) 331-4900 Atlanta, GA index.html (352) 331-4975 fax 1-800-ACS-2345 http://www.asbs.org/ http://www.cancer.org National Association of and Associated Disorders American Dietetic Association P.O. Box 7 216 West Jackson Boulevard Highland Park, IL 60035 Chicago, IL 60606-6995 (847) 831-3438 (312) 899-0040 (847) 433-4632 fax 1-800-877-1600 fax http://www.anad.org http://www.eatright.org Eat Right America Program Find a dietitian, 1-800-366-1655

76 American Heart Association National Mental Health Association 7272 Greenville Avenue 1201 Prince Street Dallas, TX 75231-4596 Alexandria, Virginia 22314-2971 (214) 706-1220 (703) 684-7722 (214) 706-1341 fax (703) 684-5968 fax 1-800-AHA-USA1 1-800-969-NMHA (1-800-242-8721) (Information Center) http://www.americanheart.org http://www.nmha.org

Stroke Connection 1-800-553-6321 Hypertension Network, Inc. http://www.bloodpressure.com

National Institute of Neurological Disorders and Stroke National Institutes of Health P.O. Box 1350 Silver Spring, MD 20911 (800) 352-9424 http://www.ninds.nih.gov

National Center on Sleep Disorders Research National Heart, Lung, and Blood Institute National Institutes of Health Two Rockledge Centre, Suite 10038 6701 Rockledge Drive, MSC 7920 Bethesda, MD 20892-7920 (301) 435-0199 (301) 480-3451 fax www.nhlbi.nih.gov and click on NCSDR

American Academy of Sleep Medicine 6301 Bandel Road, Suite 101 Rochester, MN 55901 (507) 287-6006 (507) 287-6008 fax http://www.aasmnet.org

77 A Quick Reference Tool to ACT A Quick Reference Tool to ACT

Assessment (A) and Classification (C)

BMI ≥ 30 OR ≥ Patient Measure weight, height, BMI 25 OR [(BMI 25 to 29.9 Ye s Ye s Ye s Assess risk Ye s encounter and waist circumference. waist > 35 in (88 cm) (F) waist > 35 in (F) > 40 > 40 in (102 cm) (M) factors • Assess the Calculate body mass index AND ≥ 2 risk patient’s (BMI) factors)] weight • Established status Body Mass Waist Coronary • Provide Index (BMI) Circumference Heart Disease advice, • BMI categories: • Abdominal fat • Other Athero- counseling, Overweight: increases risk. sclerotic or treatment 2 25-29.9 kg/m • High risk Disease Obesity: ≥ 30 kg/m2 F: >35 in (>88 cm) • Type 2 Diabetes • Calculate BMI as M: >40 in (>102 cm) • Sleep Apnea No follows: Measure Waist • Other Obesity Associated BMI= weight (kg) Circumference as height squared (m2) follows: Diseases

If pounds and inches • locate the upper No Risk Factors are used: hip bone and the • Smoking BMI=weight (pounds)x703 top of the right iliac height squared (inches2) crest (below figure). • Hypertension Place a measuring • High LDL-C tape in a horizontal • Low HDL-C BMI Table plane around the • Impaired fast- BMI at the ing glucose Height 25 27 30 35 level of the iliac • Family history 58” 119 129 143 167 crest. Before read- of premature 59” 124 133 148 173 ing the tape meas- CHD 60” 128 138 153 179 • ≥45 yrs (M) and

Weight ure, ensure that the 61” 132 143 158 185 ≥ tape is snug, but 55 yrs (F) 62” 136 147 164 191 63” 141 152 169 197 does not compress 64” 145 157 174 204 the skin, and is par- 65” 150 162 180 210 allel to the floor. 66” 155 167 186 216 The measurement 67” 159 172 191 223 is made at the end 68” 164 177 197 230 of expiration. 69” 169 182 203 236 70” 174 188 209 243 No 71” 179 193 215 250 Does patient 72” 184 199 221 258 Educate/Reinforce want to lose 73” 189 204 227 265 weight? For a complete BMI Table see iIiac crest • Advise to Appendix A. maintain weight • Address other risk factors • Periodic weight, BMI, and waist cir- Measuring-Tape Position cumference for Waist (Abdominal) check (every 2 Circumference in Adults years)

79 Treatment (T)/Follow-up

Progress Periodic weight, R Ye s Clinician and patient Ye s being Ye s Maintenance Ye s n (M) ) devise goals and made/goal counseling BMI, and waist treatment strategy achieved? circumference check for weight loss and risk • Dietary therapy factor control • Behavior therapy No • Physical activity Set Goals • Advise patent to lose Assess reasons for 10% of initial weight failure to lose • 1-2 lbs/wk weight for • 6 months of therapy Ye s

OPTION 1 OPTION 2 OPTION 3

BMI 25-29.9 and BMI ≥ 27 and ≥ 2 risk BMI ≥ 35 and ≥ 2 risk ≥ 2 risk factors or factors or factors or BMI ≥ 30 BMI ≥ 30 BMI ≥ 40

Lifestyle Therapy Pharmacotherapy Weight Loss Surgery • Diet: • Adjunct to lifestyle 500-1000 kcal/day therapy. Consider • Consider if other reduction if patient has not weight loss 30% or less total lost 1 lb/wk after 6 attempts have kcal from fat months of lifestyle failed. ~15% total kcal therapy. • Vertical banded from protein • Orlistat - 120 mg gastroplasty or ≥55% of total kcal or 120 mg po tid gastric bypass from CHO. before meals • Lifelong medical • Physical Activity: • Sibutramine - monitoring Source: Full text of the Practical Guide to Initially, 30-45 5,10,15 mg; the Identification, Evaluation and Treatment mins. of moderate 10 mg po qd to activity, 3-5 times start may be of Overweight and Obesity in Adults is a week. increased to 15 available from the National Heart, Lung and Eventually 30 mins mg or decreased Blood Institute Health Information Center of moderate acti- to 5 mg. at (301) 592-8573 or can be downloaded vity on most days. from the NHLBI’s Aim for a Healthy • Behavior Therapy Weight Web page at www.nhlbi.nih.gov and click on “Aim for a Healthy Weight.” Also, available from NAASO at www.naaso.org

80

DISCRIMINATION PROHIBITED: Under provisions of applicable public laws enacted by Congress since 1964, no person in the United States shall, on the grounds of race, color, national origin, handicap, or age, be excluded from participation in, be denied the benefits of, or be subjected to discrimi- nation under any program or activity (or, on the basis of sex, with respect to any educa- tion program or activity) receiving Federal financial assistance. In addition, Executive Order 11141 prohibits discrimination on the basis of age by contractors and subcon- tractors in the performance of Federal contracts, Executive Order 11246 states that no federally funded contractor may discriminate against any employee or applicant for employment because of race, color, religion, sex, or national origin and Executive Order 13087 prohibits discrimina- tion based on sexual orientation. Therefore, the National Heart, Lung, and Blood Institute must be operated in compliance with these laws and Executive Orders. U.S. Department of Health and Human Services Public Health Service National Institutes of Health National Heart, Lung, and Blood Institute

NIH Publication No. 00-4084 October 2000 aa