OWCH

Online Weight management Counseling

program for Healthcare providers

Module 2:
Lifestyle Practices for Weight
Management & Health Promotion
Yale-Griffin Prevention Research Center
www.yalegriffinprc.org 1
 Module 2

 Module 1 described the problem of the obesity

epidemic and the importance of lifestyle counseling.

 This module provides guidance for nutrition and

physical activity prescriptions for weight
management and optimum health.

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Eating alone will not keep a man well; he must
also take exercise. For food and exercise,
while possessing opposite qualities, yet work
together to produce health. For it is the nature
of exercise to use up material, but of food and
drink to make good deficiencies...

Hippocrates, ~400 B.C.

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Nutrition Recommendations

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 Basics for a Healthful Diet
Experts from the American Heart Association, the USDA
(United States Department of Agriculture), and the
American Cancer Society all agree that a health-promoting
diet consists of the following:

 Grains- at least ½ should be whole grain

 Fruits and vegetables in a variety of colors and types (the new
recommendations for adults are 9 servings per day, 4 fruits and 5
vegetables)
 Lean protein- includes 2 servings of fish per week, and 4 servings of
low and no-fat dairy products

www.health.gov/dietaryguidelines/ 5
6
 Determining Caloric Needs
 Everyone has unique caloric needs.
 Two methods to calculate individual caloric needs follow.
 The first calculation is easier but provides an
approximation.
 The second calculation requires more computation but is
more accurate.
 Consider referring patients to a dietitian/nutritionist.
 A calorie calculator can be accessed at:
 www.bcm.edu/cnrc/caloriesneed.htm

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 Method 1
To maintain current body weight
• Determine weight in kilograms (1kg=2.2lb).
• Determine activity level (use chart below to calculate.
• Calculate energy needs in calories (kcal) based on activity level.
To lose Weight: subtract 500 kcals per day for a 1 lb. wt. loss per wk.

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 Method 2
The Harris-Benedict Equation

Uses age, height, and weight to estimate basal energy

expenditure (BEE) (aka BMR) (amount of calories needed to
maintain the body's normal metabolic activity, i.e. respiration,
maintenance of body temperature etc.)

 For women, the B.E.E. =

655.1 + (9.6 x Wt. kg) + (1.8 x Ht. cm) - (4.7 x Age)

 For men, the B.E.E. =

66.5 + (13.8 x kg) + (5.0 x Ht. cm) - (6.8 x Age)
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 Method 2, cont’d
The BEE value is then multiplied by an activity factor to
estimate daily calories needed to maintain current weight.

To lose weight, subtract 500 calories per day for a 1 lb. weight
loss per week.
ACTIVITY FACTOR
Very Light = 1.3 for both women &
men
Light = 1.5 for women; 1.6 for men
Moderate = 1.6 for women; 1.7 for
men
Heavy = 1.9 for women; 2.1 for men
ACTIVITY DESCRIPTION
Seated and standing activities, driving,
cooking, playing a musical instrument
Golf, sailing, housecleaning, childcare,
walking 2.5-3.0 mph
Dancing, skiing, tennis, cycling,
walking 3.5-4.0 mph
Basketball, football, soccer, climbing

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 Improving the Typical American Diet

 Control portion size and total calorie intake

 Replace ‘bad’ fats with ‘good’ fats
• Reduce trans-fat & saturated fat consumption
 Reduce refined carbohydrates
 Increase whole grains consumption
 Increase fiber intake
 Reduce sodium intake
 Increase micronutrient consumption
 Increase fruit and vegetable consumption

Katz DL. TIME Magazine / ABC News Summit on Obesity; Williamsburg, VA: June 2004

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 Summary of Nutrition Recommendations

1. To maintain a healthy body weight, balance calories consumed

with calories burned.
2. Increase awareness of daily caloric requirements and calorie
content of foods for portions typically consumed.
3. Consume a diet rich in a wide variety of fruits and vegetables
(not fruit juices), especially that that are brightly colored
(spinach, carrots, peaches, and berries, etc.).
4. Prepare foods with little or no saturated or trans fat, salt, or
sugar.
5. Choose whole-grain, high-fiber foods.

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Summary of Nutrition Recommendations, cont’d

6. Minimize beverages and foods with added sugars.

7. Choose lean meats or vegetable protein alternatives and fat-
free (skim) or low-fat (1% fat) dairy products to avoid excess
saturated fat & cholesterol.
8. Eat 2 servings of fish twice weekly, especially those high in
omega-3 fatty acids (e.g., salmon, trout, herring). (Children
and pregnant women should follow FDA guidelines for
avoiding mercury-contaminated fish such as shark,
swordfish, king mackerel, tilefish.)
9. Be aware of portion size and foods prepared with saturated
fats, salt or sugar when eating out.

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Summary of Nutrition Recommendations, cont’d

10. Limit sodium intake to < 2,300 mg of sodium daily: prepare

foods with little or no salt; beware of processed foods.
Older adults, African Americans, and hypertensive patients
should consume no >1,500 mg of sodium daily.
11. Limit alcohol intake to no >1 drink per day for women and 2
drinks per day for men (1 drink = 12 oz of beer, 4 oz of wine,
1.5 oz of 80-proof spirits, or 1 oz of 100-proof spirits).

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 Convey the Importance of Label Reading

% Daily Values are based

on a 2,000 calorie diet.

Website to understand
and see the Nutrition Facts
label:
http://www.cfsan.fda.gov/~d
ms/foodlab.html#see1

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Energy Balance

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 Energy Balance
 Energy balance is key to weight control.
 In order to lose weight, calorie expenditure must be
greater than calories intake (negative energy
balance).
 One pound of body fat represents a reserve of
approximately 3500 kcal.
 To lose 1 pound per week, a deficit of 500 calories
per day is required.
 This can be achieved through increased physical
activity and/or decreased caloric intake.
Spiegelman BM et al. Obesity and regulation of energy balance. Cell 2001; 104: 531-543
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 Energy Balance

Physical inactivity and sedentary lifestyles lead to caloric

imbalance and the development of obesity.

Adjustments in caloric intake and the frequency, duration &

intensity of exercise are needed to promote weight loss.
http://mechanismsincardiology.com/
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10
 Intake Expenditure

A cookie and a Walking for 45

Soda= 200 calories minutes= 200 calories

Every day=
73,000 calories a year= 73,000 of calories a year=
A 22 pound increase a year A 22 pound decrease
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Physical Activity

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 Physical Activity
 A reduction in calorie intake without physical activity will result in a
decline in the Resting Metabolic Rate thus inhibiting weight loss.
 Combining physical activity with a balanced diet is key to achieving
sustainable weight loss and associated health benefits.
 To promote and maintain health, adults require moderate-intensity
aerobic (endurance) physical activity for a minimum of 30 minutes on
five days each week or vigorous-intensity aerobic physical activity for
a minimum of 20 min on three days each week.
 Shorter 10 minute bouts of activity may be performed to reach the
30 minute goal.

Weinsier RL. Do Adaptive changes in metabolic rate favor weight regain in weight-reduced individuals? An examination of the set-point
theory. Am J Clin Nutr 2000; 72: 1088-1094.
American College of Sport’s Medicine. ACSM’s Guidelines for exercise testing and prescription. 7th Edition. Lippincott- Williams & Wilkes
Physical activity recommendations included in the Dietary Guidelines for Americans 2005 (US Department of Health and Human Services,
2005 21
 Physical Activity
 A variety of activities can be combined to meet the
recommendation.
 To prevent unhealthy weight gain some adults must
exceed minimum requirements to achieve energy
balance (45-60 minutes of moderate physical activity
per day).
 To sustain weight loss in adulthood: Participate in at
least 60–90 min of daily moderate-intensity physical
activity while not exceeding caloric intake
requirements.
Haskell W, et al. Physical Activity and Public Health: Updated Recommendation for Adults from the American College of Sports
Medicine and the American Heart Association. MEDICINE & SCIENCE IN SPORTS & EXERCISE. 2007; Am College of
Sports Medicine and Am Heart Assoc 22
 Physical Activity
 A dose-response relationship exists between
physical activity and health: activity above
recommended minimum = increased benefits.
 Weight training on 2 non-consecutive days is
recommended to enhance skeletal muscle
strength and endurance:
 8-12 exercises using major muscles
 8-12 repetitions of each exercise to volitional
fatigue.
Haskell W, et al. Physical Activity and Public Health: Updated Recommendation for Adults from the American College of Sports
Medicine and the American Heart Association. MEDICINE & SCIENCE IN SPORTS & EXERCISE. 2007; Am 23 College of
Sports Medicine and Am Heart Assoc
 Resistance Training
and Energy Expenditure

Increasing the body muscle mass via resistance training (weight

lifting) can increase resting energy expenditure by 30-50 kcal/lb
muscle a day.

Example: if 20 minutes of resistance training 3 times

a week for a duration of 6 weeks adds 4lbs. of muscle,
200 extra kcal per day would be burned as a result of an
increase in the resting metabolic rate.

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 Strategies to incorporate
physical activity into daily life

 Take the stairs.

 Park further away.
 Stand up and take walks throughout the day.
 Schedule exercise time.
 Join a fitness group or club.

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 Physical Activity Rx
 To attain the maximum health benefits from
physical activity, exercise should be prescribed.

 The exercise prescription consists of the FITT

acronym:

1) Frequency
2) Intensity
3) Time
4) Type
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 Frequency

 At least 5 times a week of moderate physical

activity or 3 times a week of vigorous activity.

 At least 2 times a week of progressive weight

training.

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 Intensity

Methods to measure intensity include:

 Talktest
 Target heart rate

 Borg’s rating

 METS (metabolic equivalent)

http://www.cdc.gov/nccdphp/dnpa/physical/measuring/talk_test.htm
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 Talk Test
This method of determining intensity is very
basic:

 Light intensity – able to sing while being

active.
 Moderate intensity - able to talk but not sing.
 Vigorous activity – unable to say more than a
few words without taking a breath (unable to carry
on a conversation).
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 Target Heart Rate
Determine if the pulse or heart rate is within the target zone
during physical activity:
 Moderate intensity: 50%-70% of the maximum heart rate
 Vigorous intensity: 70%-85% of the maximum heart rate

Maximum heart rate (MHR) can be assessed in a sports

medicine laboratory or estimated:

220 – age = MHR for males

226 – age = MHR for females

www.cdc.gov/physicalactivity/everyone/measuring/heartrate.html
Waburton d, et al. Prescibing exercise as preventive therapy. CMAJ 2006l 174L961-74.

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 Examples of Target Heart Rate
Moderate intensity exercise (50%-70% MHR)
Example: Target Heart Rate for a 45 year old man
 HR max (220 – age) = 220 – 45 = 175 beats/min
 50% - 70% of MHR = 88 -123 beats/min

High-intensity exercise (70%-85% MHR)

Example: Target Heart Rate for a 25 year old man
 HR max (220 – age) = 220 – 25 = 195 beats/min
 70% -85 % of MHR = 137 - 166 beats/min

www.cdc.gov/physicalactivity
Waburton DER et al. Prescribing exercise as preventive therapy. CMAJ 2 2006; 174: 961-974.

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 Borg’s Rating of Perceived Exertion
 Borg’s Rating is based on the physical sensations a person
experiences during physical activity.
 The scale ranges from 6 to 20, where 6 means "no exertion at all"
and 20 means "maximal exertion.”
 Borg’s rating of 12-14 would be moderate intensity activity.
 Although this is a subjective measure, a high correlation exists
between a person's perceived exertion rating times 10 and the
actual heart rate during physical activity. For example, if a
person's rating of perceived exertion (RPE) is 12, then 12 x 10 =
120; the heart rate should be approximately 120 beats per minute.
http://www.cdc.gov/physicalactivity/everyone/measuring/exertion.html

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 METS - Metabolic Equivalent
 MET or the standard metabolic equivalent is a unit used to
estimate the amount of oxygen used by the body during
physical activity.
 1 MET = BMR (energy (oxygen) used by the body at rest)
With increased activity, more oxygen is consumed and the
MET level increases.
 3 to 6 METs = moderate-intensity physical activity.
 > 6 METs = vigorous-intensity physical activity.

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 METs examples
3 – 6 METS > 6 METS
Brisk walk Jogging, running, speed walking

Bicycling < 10 mph Bicycling > 10 mph

Ballroom dancing Swimming laps

General gardening Heavy gardening

Tennis, doubles Tennis, singles

Weight lifting- Nautilus or free Circuit training

weights
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 Time
Accumulate total minimum of 30 minutes of
moderate activity or 20 minutes of vigorous activity
per day for weight maintenance.

 Schedule one routine time for exercise, or

 Split total time into 2 or 3 exercise sessions throughout

day.

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 Time, cont’d
 Higher intensity exercise burns more calories
in shorter time period, but may increase the
risk of injury.
 Lower intensity exercise for a longer duration is
recommended for beginners (e.g., brisk walking).
 As fitness level increases, increase either time,
intensity or both to increase total caloric
expenditure.
 Pedometers can also be used to target >5,000
steps per day.
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The Association Between Time and Intensity

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 Type
 Cardiovascular Exercise: is best determined by
preferences, skills, risk of injury, availability of
facilities, and ability to initiate and maintain moderate
level exercise.
 Uses LARGE muscle groups for extended periods of
time.
 Improves cardiovascular measures and health
parameters:
1) Oxygen consumption
2) Cardiac output, stroke volume, resting heart rate
3) Blood pressure control
4) Glucose tolerance
5) Increase HDL, Lower LDL 38
 Type, cont’d
Choose type of cardiovascular exercise best
suited to individual lifestyle:
 Walking programs are well accepted as an easy place to start
that most individuals can follow, with only minimal
requirements – i.e., appropriate shoes, and a time and place to
walk.
 A couple that loves ballroom dancing and dance once a week
should be encouraged to adhere to this activity and increase
the frequency to at least 3 times a week on a regular basis.
Hayden JA et al. Exercise therapy for treatment of non-specific low back pain. Cochrane Database of Systematic Reviews 2005, Issue
3. Art. No.: CD000335. DOI: 10.1002/14651858.CD000335.pub2.
Peterson J. Get moving! Physical activity counseling in primary care. Journal of the American Academy of Nurse Practitioners; 2007;
19:349–357

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 Type, cont’d

Strength training: decreases the risk of injury, facilitates faster

weight loss/control, and increases basal metabolic rate (BMR).
 Recommended at least 2 days a week to work all the major muscle
groups (legs, hips, back, chest, abdomen, shoulders, and arms).
 Type depends on risk of injury and access to various modalities:
 Light weights

 Resistance bands

 Machines

 Free weights

www.cdc.gov/physicalactivity/everyone/guidelines/adults.html

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Physical Activity Resources
1) Fitness Centers
 Certified fitness professionals
 Associations

 Positives – assists in motivation, scheduling

 Negatives – variations in quality, costs

2) Books
 Easy to find
 Variations in quality

 No additional external forces to assist in motivation

3) Community groups

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 The Exercise Prescription
 Physicians can have an enormous impact on patient decision
to begin a physical activity program.
 Prescription of physical activity based on the FITT acronym
(Frequency, Intensity, Type, Time).
 Recommendations should consider individual patient need,
initial ability to perform physical activity, interest level and
general health conditions.

The following principles should be conveyed to patients prior

to embarking on a physical activity program.
Estrabrooks PA et al. Physical activity promotion through primary care. JAMA 2003; 289: 2913- 2916.
Chakravarthy MV et al. An obligation for primary care physicians to prescribe physical activity to sedentary patients to reduce the
risk of chronic health conditions. MayoClinic Proc 2002; 77: 165-173.
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 The Exercise Prescription
1. Begin physical activity with light intensity activity, particularly if no
previous exercise pattern; gradually increase the amount and
intensity of activity until the goal is reached.
2. For health benefits, at least 30 minutes of moderate activity on
most days is required.
3. 60-90 minutes of activity per day are required for over-weight/obese
patients, CHD and CAD patients (e.g., hypertension and diabetes).
4. To encourage adherence to a lifestyle change, the type of physical
activity should be based on patient preference.
5. Remind patients to seek medical attention if chest pain occurs while
exercising.
6. Cardiac patients should begin an exercise program under
supervision in a cardiac rehab center.
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A Generic Exercise Prescription

Physical Activity prescription

Frequency: 5 times a week
Intensity: Gradually increase until 75% of maximum heart rate or
until finding it difficult to converse when exercising
Type: Based on personal preference
Time: Gradually increase until reaching 30-90 minutes a day (based
on risk)
Caution: If you feel chest pain, stop immediately and return to
your doctor for a check up
Additional advice: Adhere to a balanced diet, combining
physical activity while watching caloric intake. Substitute the stairs
for an elevator; walk or ride your bike instead of driving your car.
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 Exercise Prescription Example

Patient A: A 60 year old woman, BMI of 25, with no previous physical

activity pattern and no physical limitations to exercise.

 Goal: To start an exercise program and maintain it.

 Preferred activities: Low-moderate intensity exercise (walking

and gardening) 7 days per week.

Adapted from Warburton et al. Prescribing exercise as preventive therapy. CMAJ; 2006; 174: 961-974.

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 Exercise Prescription Example, cont’d
 F = Frequency = 5-7 times a week
 I = Intensity = Low-moderate intensity exercise

MHR (226-age) = 220-60 = 160 beats/min

50% - 70% of MHR = 80-112 beats/min
Training range = 80-112beats/min

 T = Type and Time: Walking briskly for 30 minutes daily,

weeding & watering the garden for 30 minutes twice a week.

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 Summary
 It is essential for physicians to convey the basics of a
healthful diet and the importance of a physically active
lifestyle to patients.
 Studies have shown that simply advising patients
without specific assistance and follow-up is ineffective.
 Only 8.2% of total outpatient visits included counseling
or education related to exercise.
 Intervention activities need not be time-consuming and
can be conducted by office staff as well as the physician.

Estabrooks PA et al. Physical activity promotion through primary care. JAMA 2003; 289: 2913-2916.

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 Summary
 Patients must be active decision-makers and
set realistic goals.
 Establishing specific goals and action plans
prove most successful.
 Counseling and follow-up are critical for
success.
 Intervention activities must consider the
patient’s social & physical environment.
Integration with community opportunities for
physical activity is important.
Balasubramanian B, et al. Practice-Level Approaches for Behavioral Counseling and Patient Health Behaviors. Am J Prev Med.
2008; 35;5:S407-S413 48
 The next module (Module 3) provides an
overview of behavior modification constructs
that pertain to lifestyle counseling efforts.

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