NUTRITION FOR OBESITY MANAGEMENT PART I Jennifer Brown, MSc., RD 8th Learning Retreat on the Principles and Practice of Interdisciplinary Obesity Management for Dietitians Toronto, Canada October 25-26, 2017 @thebariatricrd
FACULTY/PRESENTER DISCLOSURE FACULTY Jennifer Brown RELATIONSHIPS WITH COMMERICAL INTERESTS Speakers Bureau/Honoraria: DC/CON Consulting Fees: DC, AFHTO, CON, Celebrate Vitamins Other: Employee of the Ottawa Hospital Bariatric Centre of Excellence; Co-chair of OBN Dietitian Working Group
OBJECTIVES PART I: Applying the science of obesity and weight physiology into practice Provide education, counselling and support for your patients experiencing weight regain How to have the conversation about obesity management
Medical Nutrition Therapy (MNT) Nutrition Sciences/ Metabolism Evidence- Focus Based on Obesity Management health & wellness (not weight or BMI) Behaviour Change/ Counselling Exercise & Physiology Egger G, Swinburn B. BMJ. 1997;315(7016):477-480.
USING HAES IN OBESITY MANAGEMENT Weight Inclusivity Health Enhancement Respectful Care Eating for Well-Being Life-Enhancing Movement
NEW PROPOSED DEFINITION OF OBESITY Abnormal or excess body fat that IMPAIRS health Proposed changes: 1) No longer use BMI alone to define obesity 2) Use a 3-pronged assessment: Amount of body fat Distribution of body fat Physiological impact of body fat Mechanick, JL., Hurley, DL. & Garvey, WT. Endocr Pract. (2017) 23(3):372-378
Abnormal or excess body fat that IMPAIRS health Medical Nutrition Therapy (MNT) Evidence- Based Obesity Management Nutrition Sciences/ Metabolism Behaviour Change/ Counselling Exercise & Physiology Egger G, Swinburn B. BMJ. 1997;315(7016):477-480.
CHRONIC DISEASE MANAGEMENT Behaviour/Life Changes Surgery Diagnosed with Obesity Structured Interventions Medications
AVAILABLE TREATMENT NO TREATMENT Body Weight Change (%) Life changes = 3-5% Meal replacements = 5-10% Medications = 5-10% Surgery = 15-35%* Years after weight loss
Mann T, et al. Am Psychol. 2007;622(3):220-233. REVIEW STUDIES - DIETS
VARIATION IN INDIVIDUAL RESPONSES TO DIETS Presented by Kaplan, LM. Harvard Blackburn Course in Obesity Medicine, 2016/06/22 Adapted from Gardner, CD, et al, JAMA, 2007. Courtesy of conscienhealth.org
VARIATION IN INDIVIDUAL RESPONSES TO MEAL REPLACEMENTS Studied: 1,500 women Age: 30 60 years old All on Optifast + Behaviour/Life skills (either 6 or 12 weeks) Weights measured at end of program EVERYONE RESPONDS DIFFERENTLY Azar, M., et al. Obesity (2016); 24:805-811. Slide courtesy of Dr. Bob Dent
VARIATION IN INDIVIDUAL RESPONSES TO MEDICATIONS & SURGERY Presented by Kaplan, LM. Harvard Blackburn Course in Obesity Medicine, 2016/06/22. Courtesy of conscienhealth.org
ROUX-EN-Y GASTRIC BYPASS SURGERY Sjostrom L. J JAMA 2012; 307(1):56-65..
WEIGHT TRAJECTORIES AFTER RYGB Courcoulas, AP, et al. JAMA. 2013;310(22):2416-2425..
Change our understanding and outlook
- Isn t eating well - Isn t able to move/exercise - Isn t sleeping well - Isn t happy 150 lbs 10 lbs
X X
LIFELONG MANAGEMENT OF OBESITY Body Weight Change (%) Meal replacements Life changes Medication Years
LIFELONG MANAGEMENT OF OBESITY Body Weight Change (%) Surgery Life changes Medications Years
CHRONIC DISEASE MANAGEMENT Behaviour/Life Changes Surgery Diagnosed with Obesity Structured Interventions Medications
PATIENTS ARE SCARED OF GAINING WEIGHT
I m able to eat more I m hungry all the time I can t stop craving. I ve gain some weight I m terrified of gaining more weight..or going back to my old habits
STEP 1: Listen Acknowledge Ask Assess Assist WHAT TO DO WHEN PATIENTS ARE CONCERNED ABOUT WEIGHT GAIN
STEP 1 Stopped exercising WEIGHT GAIN What we see Poor food choices and eating habits Not following post-op behaviours WHY (root causes) Injured back Skipping breakfast Pain Working shift work Elevated stress Poor sleep hygiene
WHAT TO DO WHEN PATIENTS ARE CONCERNED ABOUT WEIGHT GAIN STEP 1: Listen Acknowledge Ask Assess Assist STEP 2: Determine their weight outcomes How much they lost after surgery Calculate wt trajectories How long it took them When did they notice weight increasing
STEP 2: DETERMINE WEIGHT OUTCOMES Calculate nadir % total weight loss Pre-intervention wt nadir wt (lowest wt) Pre-intervention wt x 100 Calculate current % total weight loss Current wt nadir wt (lowest wt) Current wt x 100
STEP 2: DETERMINE WEIGHT OUTCOMES Calculate nadir % total weight loss Pre-surgery wt (post-optifast) nadir wt (lowest wt) Pre-surgery wt (post-optifast) x 100 Pre-sx wt: 280 lbs Nadir wt: 175 lbs TWL = 105 lbs (38%) Calculate current % total weight loss Pre-surgery wt (post-optifast) current wt x 100 Pre-surgery wt (post-optifast) Pre-sx wt: 280 lbs Today s wt: 190 lbs TWL = 90 lbs (32%) 38% TWL 32% TWL 1-2 years post RYGB = 20-35% SG = 15-25% 15 lbs weight gain
STEP 2: DETERMINE WEIGHT OUTCOMES Calculate hypothetical weight trajectories Average weight gain = 0.5-2kg/year (1-4.5 lbs/yr) Pre-menopause women/men 1-5% per year ~320-357 lbs Post-menopause women 5-7% per year ~214-231 lbs BONUS: figure out the average weight gained/year
STEP 2: DETERMINE WEIGHT OUTCOMES Weight change timeline questions 1) How far post-op is the patient? 4 years 2) How long did it take to reach your lowest weight after surgery? (in months) 9 months 3) How long were you able to stay around this weight? 2 years 4) When did you start noticing your weight increasing? ~6 months ago
WHAT TO DO WHEN PATIENTS ARE CONCERNED ABOUT WEIGHT GAIN STEP 1: Listen Acknowledge Ask Assess Assist STEP 2: Determine their weight outcomes How much they lost after surgery Calculate wt trajectories How long it took them When did they notice weight increasing STEP 3: Assess quality of life factors Hunger/appetite Sleep Stress Energy Pain Happiness Mood Overall health
Step 3: Assess quality of life factors Ask patient to rate the following items on a 1-10 scale (1 = poor/low and 10 = good/high) Energy (3/10) Mood (5/10) Stress (9/10) Sleep (2/10) Pain (8/10) Hunger (8/10) Cravings (10/10) Appetite (9/10) Overall health (6/10) Other
Poor food choices and eating habits Injured back Skipping breakfast Stopped exercising WEIGHT GAIN Not following post-op behaviours Pain Working shift work PUT IT ALL TOGETHER Normalize weight gain Get to the root causes Use motivational interviewing to assess patients readiness Refer to health providers as needed Offer a Weight Regain Course Elevated stress Poor sleep hygiene
Managing Weight Regain Course PART 1 Understanding Obesity PART 2 Hormones & Obesity PART 3 Gut Bacteria & Obesity PART 4 Lifelong Management of Obesity
OUTSMART THE BRAIN 1) Change your food environment 2) Make sleep a priority 3) Manage stress/coping skills 4) Eat foods high in fibre and protein 5) Be aware of food reward 6) Make the body move Adapted from Guyenet, SJ. The Hungry Brain. 2017.
PATIENT RESOURCES The Hungry Brain: Outsmarting the Instincts that Make us Overeat by Stephan J. Guyenet www.stephanguyenet.com/thehungrybrain CON Webinars: www.obesitynetwork.ca/webinars Time to Act on Obesity: https://youtu.be/az0durd_gxw Poodle Science: https://youtu.be/h89qqfxtc-k
Thank you Jennifer Brown, MSc., RD 613-798-5555 ext. 10532 jebrown@toh.ca @thebariatricrd jenniferbrownvowles
REFERENCES See attached list