Summary of Modules
Module 1 provides an overview of the obesity epidemic and explains the importance of lifestyle counseling to promote health. Module 2 provides guidance for nutrition and physical activity prescriptions for weight management and optimum health. Module 3 reviews theories of behavior modification. Module 4 presents the Pressure System Model, a behavior change construct tailored to, and tested in, the primary care setting.
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World Pandemic
According to the WHO, 1.6 billion adults worldwide were overweight in 2005. At least 400 million adults were obese. At least 20 million children <5 years were overweight. WHO predicts that 2.3 billion adults will be overweight and 700 million will be obese by the year 2015.
http://www.who.int/mediacentre/factsheets/fs311/en/index.html 5
World Pandemic
The United States can be regarded as the epicenter of this global pandemic. Overweight and obesity affects 65%-80% of American adults, and a rising proportion of children. Obesity is a major, modifiable risk factor for type 2 diabetes and cardiovascular disease.
Katz DL. (2007) Nutrition in Clinical Practice. Lippincott Williams & Wilkins
www.cdc.gov/nccdphp/dnpa/obesity/index.htm
2007
No Data 24%
<10% 25 %29%
10%14% 30%
15%19%
20%
10
25 6 - 11 12 - 19
5 6.6 5
CDC, National Center for Health Statistics, National Health and Nutrition Examination Survey
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12
% Difference 15 %
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14
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Adults
Population weight trends are measured using the body mass index (BMI) which is the weight in kilograms divided by the height in meters squared (BMI=kg/m2)
Children
Growth charts show the weight status categories used with children and teens. www.cdc.gov/nchs/about/major/nhanes/growthcharts/charts.htm
Percentile Range <5th percentile 5th - 84.9th percentile 85th - 94.9th percentile 95th percentile
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18
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Endometrial, colorectal, prostate, pancreatic, breast, esophageal and renal cell cancers Hypertension, cardiovascular disease, DVT, CVA Osteoarthritis, rheumatoid arthritis, gout, carpal tunnel syndrome, low back pain Type 2 Diabetes; Gall bladder disease Menstrual abnormalities, infertility, stress incontinence Asthma, sleep apnea, respiratory impairment
The incidence of co-morbidities related to obesity and overweight. BMC Public Health 2009, Mar 25:9:88 Callee et al. Obesity, recreational physical activity, and risk of pancreatic cancer in a large U.S. Cohort. Cancer Epid Biomarkers Prev, 2005 Feb;14(2):459-66 Callee et al. Body mass index, weight change, and risk of prostate cancer in the Cancer Prevention Study II Nutrition Cohort. Cancer Epid Biomarkers Prev. 2007 Jan;16(1):63-9. A prospective study of waist circumference and body mass index in relation to colorectal cancer incidence. Cancer Causes Control. 2008 Sep;19(7):783-92 Callee et al. The role of body weight in the relationship between physical activity and endometrial cancer: results from a large cohort of US women. Int J Cancer. 2008 Oct 15;123(8):1877-82 Maguire M. Impact of obesity on women's health. Fertility and Sterility, May 2009 Vol 91, Issue 5. American Obesity Association 21
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10.65 13.97 64.53 10.04
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Abdominal Obesity
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Hofbauer KG. Molecular pathways to obesity. International Journal of Obesity 2002; 16:S18- S27. 27
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Energy Balance
Although genetics and the environment are contributing factors in deterring body fat mass accumulation, energy balance is of paramount importance in weight regulation. If intake is too high obesity will develop. Maintaining an appropriate energy balance of food intake and physical activity is a crucial preventive measure.
Hofbauer KG. Molecular pathways to obesity. International Journal of Obesity 2002; 16: S18- S27. Current Trends in Weight Management: What Advice Do We Give to Patients? Clinical Diabetes Volume 26, Number 3, 2008
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A healthful diet and physical activity are crucial components of weight loss/control. Recent research shows 76% of US adults had inadequate fruit & vegetable intake and 65% did not exercise. Eating well and being active have been linked to the prevention of comorbidities related to obesity and weight gain, such as diabetes and the metabolic syndrome. Interventions during the phase of insulin resistance, particularly supervised weight loss, mitigate cardiovascular risk and prevent diabetes. Behavioral changes for long-term adherence are key components.
Balasubramanian BA, Cohen DJ, Clark EC, Isaacson NF. Practice-level approaches for behavioral counseling and patient health behaviors. Am J Prev Med; 2008 Nov;35:S407-13.
Hu FB et al. NEJM. 2001;345:790-7 Magkos et al. Management of the Metabolic Syndrome and Type 2 Diabetes Through Lifestyle Modication. Annu. Rev. Nutr. 2009. 29:8.18.34r 30
Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. NEJM 2002; 346: 39331 403.
DPP - Results
The incidence of diabetes was 11.0, 7.8, and 4.8 cases per 100 person-years in the placebo, metformin, and lifestyle group respectively. The lifestyle group reduced the incidence of diabetes by 58%, and metformin by 31% in comparison to the placebo.
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30 20 10 0 0 1 2 3 4
Metformin Lifestyle
DPP - Conclusion
To prevent one case of diabetes during a period of three years, 7 people would have to participate in the lifestyle-intervention program, and 14 would have to receive metformin. Lifestyle changes and treatment with metformin both reduced the incidence of diabetes in persons at high risk. The lifestyle intervention was more effective than metformin.
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Risk Factor Abdominal obesity (Waist circumference) Men Women TG HDL-C Men Women Blood pressure Fasting glucose
Defining Level
>102 cm (>40 in) >88 cm (>35 in) >150 mg/dL <40 mg/dL <50 mg/dL >130/85 mm Hg >110 mg/dL
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- Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497. - http://www.nhlbi.nih.gov/guidelines/cholesterol/
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Finnish Diabetes Prevention Study Does Treating Metabolic Syndrome Make a Difference?
522 middle-aged, overweight adults, (BMI 31) 172 men and 350 women Mean duration 3.2 years Intervention Group: Individualized counseling to Reduce body weight and reduce dietary fat & saturated fat Increase dietary fiber and physical activity Control Group Usual care; annual physical exam General dietary and exercise advice at baseline
Tuomilehto J et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. NEJM 2001; 344: 1343-1350. 40
% of subjects
Intervention
11%
(615 CI) Intervention Control
Tuomilehto J et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. NEJM 2001; 344: 1343-1350.
% with Diabetes
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Physical Activity
A large body of scientific evidence has shown that physical activity has a protective effect against numerous chronic diseases and mortality. Sufficient physical activity = at least moderately active for 30 minutes or more on most days of the week. This amount of exercise can decrease risk of metabolic syndrome. Resistance training 2 days/week is recommended to promote lean body mass and muscle strength. Health care providers can play an important role in encouraging physical activity.
www.cdc.gov/nccdphp/sgr/pdf/sgrfull.pdf; Jakicic JM, Marcus BH, Gallagher KI, et al. Effects of exercise duration and intensity on weight loss in overweight, sedentary woman. JAMA 2003; 290: 1323-1330. Blair S, LaMonte M, Nichaman M. The evolution of physical activity recommendations: how much is enough? Am J Clin Nutr. 2004; 79 (5) Verghese J, Lipton RB, Katz MJ, et al. Leisure activities and risk of dementia in the elderly. NEJM 2003; 348: 2508-2516. Ainsworth BE, Youmans CP. Tools for physical activity counseling in medical practice. Obesity Research 2002; 10: 69S- 78S. Johnson J, Slentz C, Houmard J, et al. Exercise training amount and intensity effects on metabolic syndrome. Am J Cardol; 2007 Dec 15;100(12):1759-66.
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Recurrent falls (SR of RCTs) Hip fracture (Cs) Breast cancer (SR of Cs, D) Colon cancer (SR of Cs, D) Chronic fatigue (RCTs) Fibromyalgia (RCTs) Sleep disorders (RCTs) Gallbladder stones (Cs, D) Diverticulosis (Cs) Prostate hypertrophy (Cs, D) Sexual dysfunction (RCTs)
Yusuf S. Effect of coronary artery bypass graft surgery on survival: overview of 10-years results from randomized trial by the Coronary Artery Bypass Graft Surgery Trialists .Collaboration. Lancet 1994; 344: 563-570 .Van de Werf. Access to catheterization facilities in patients admitted with acute coronary syndrome: multinational registry study. BMJ 2005; 330: 441-447 .Doll R. Mortality in relation to smoking: 50 years observations on male British doctors. BMJ 2004; 328: 1519-1527 48
Hypertension Studies:
A meta-analysis by Whelton (2002) has shown that aerobic exercise is associated with a significant reduction in mean systolic and diastolic blood pressure (-3.84mm Hg and -2.58 mm Hg respectively). The reduction was seen in both normotensive and hypertensive patients alike. An increase in aerobic physical activity should be considered an important component of lifestyle modification for prevention and treatment of high blood pressure. According to the JNC7, aerobic physical activity is recommended for pre-hypertension and hypertension stages I and II. In overweight hypertensive patients, a combined exercise and weight-loss intervention has been shown to decrease SBP and DBP by 12.5 and 7.9 mm Hg, respectively.
Whelton SP, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure: A meta-analysis of randomized, controlled trials. Annals of Internal Medicine 2002; 136: 493-506. Appel L, Champagne C, Harsha D. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. JAMA; 2003 Apr 23-30;289(16):2083-93. www.nhlbi.nih.gov/guidelines/hypertension/
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Lifestyle Counseling
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Katz DL et al. Impact of an educational intervention on internal medicine residents' physical activity counseling: The Pressure System Model. Journal of Evaluation in Clinical Practice. In Press.
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Patient-Provider Encounter
Americans average 2.7 office visits per person per year, with most (60%) occurring in a primary care setting. Patients regard physicians as a resource for preventive health information and recommendations. Many patients would like their doctor to focus more on prevention. Patients counseled by primary care physicians to make lifestyle changes and who target a specific change are more likely to make an attempt and to be successful.
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Elley CR et al. Effectiveness of counseling patients on physical activity in general practice: cluster randomized controlled trial. BMJ 2003; 326: 793.
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PACE+
for Adolescents
using an interactive computer program and focusing on provider counseling to target one physical activity behavior and one nutritional behavior in need of change.
Results showed significant improvement over a 4 month period: Decreased fat consumption Increased fruit and vegetable intake Increased physical activity Adolescents who set an a-priori goal of behavior change were more likely to
change behaviors than those who did not set such goals.
Patrick K et al. A multicomponent program for nutrition and physical activity change in primary care: PACE+ for adolescents. Arch Pediatr Adolesc Med 2001; 155: 940- 946.
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At a 6 and 12 month follow-ups, patient physical activity increased significantly from baseline, compared to no change in the control. At 12 months, the intervention clinicians provided physical activity counseling 1.5 more times than they did at baseline. In comparison, no change was observed in residents in the control.
Katz DL, Shuval K, Comerford BP, Faridi Z, Njike VY. Impact of an educational intervention on internal medicine residents' physical activity counselling: the Pressure System Model. J Eval Clin Pract. 2008 Apr;14(2):294-9
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Summary of Module 1
There is strong evidence associating sedentary lifestyle and weight gain to increased morbidity and mortality. Weight loss and control have enormous potential health benefits. Lifestyle counseling in primary care can effectively encourage healthful dietary and physical activity patterns. The next module provides the information needed to provide an exercise prescription and offer constructive nutritional guidance.
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