Supported by: National Center for Minority Health and Health Disparities Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811] OBJECTIVES By the end of this segment, the community participant will be able to: 1. Identify ways to balance diet, physical activity and body weight for AIAN adults and children 2 Obesity, Body Mass Index (BMI), and overview of the growing problems Obesity is increasing among all ethnic groups in the US What behaviors are primarily related to prevention of chronic diseases include? Eating Healthy Foods Energy Taking Part in Daily Physical Activity Balance Reserving Tobacco for Ceremonial Use only Reducing Exposure to Environmental Contaminants as much as possible 4 Goals of Weight Management/Treatment Prevent further weight gain (minimum goal). Reduce body weight Maintain a lower body weight over long term BODY MASS INDEX (BMI) Calculate by weight (kg)/height 2 (m 2 ) or [weight/(pounds)/height 2 (in 2 )]*703 5 6 1
BMI is Only an Estimate Not relevant for AIANs who: Are pregnant or breast feeding Are athletes Have physically demanding jobs or roles (hunting, fire fighters, mine workers) Have physical hobbies (running, basketball) Are recovering from illness or injuries Have a debilitating chronic disease 7 QUESTION: What is obesity? Obesity = BMI > 30 QUESTION: What is the difference between being overweight and obese? Overweight = BMI 27.8 kg/m2 for men* BMI 27.3 kg/m2 for women* Normal = 18.5 24.9 & Underweight = <18.5 *Najjar MF, Rowland M. Anthropometric reference data and prevalence of overweight, United States, 1976-80. Vital Health Stat [11]. 1987;238:1-73. 8 Goals of Weight Management/Treatment Prevent further weight gain (minimum goal). Reduce body weight Maintain a lower body weight over long term 9 Health Benefits of Weight Loss Decreased cardiovascular risk Decreased glucose and insulin levels Decreased blood pressure Decreased LDL and triglycerides, increased HDL Decreased severity of sleep apnea Reduced symptoms of degenerative joint disease Improved gynecological conditions 10 Key Messages Obesity is a chronic disease All racial groups in the US and all States show an increase in obesity Native Americans are among the most obese population in the U.S. The Thrifty Gene explanation for Natives tendency to gain weight was a myth Target Weight Loss Goal weight should be 10% of current weight Plan to lose 10% in 6 months Rate of 1 to 2 pounds per week Achieve with calorie deficit of 500 to 1000 calories per day 11 12 2
Key Messages Modest weight loss (5-10% of body weight over a 6 month period of time) has significant health benefit. Most people have unrealistic weight reduction goals. 13 Key Messages Popular diets (Atkins, South Beach) show good weight loss after 6 months (better than most low calorie and exercise programs). However, after 1 year, combined low calorie diet with exercise shows the most consistent weight loss. BUT, weight loss is maintained only as long as treatment is continued (lifestyle change, exercise, medications) 14 BRFSS, 1986 BRFSS, 1987 15 16 BRFSS, 1989 BRFSS, 1990 17 18 3
BRFSS, 1992 BRFSS, 1994 19 20 BRFSS, 1996 BRFSS, 1998 21 22 BRFSS, 1999 BRFSS, 2000 23 24 4
BRFSS, 2001 Women s Health Problems related to Obesity High blood pressure (hypertension) Diabetes Hysterectomy (removal of womb) Back pain Constant tiredness 25 26 Obesity-Causes Genetic Gene mutations rare cause Adopted Children had BMI correlation with biological parents not adopted parents Environmental Pima Indians (Southwest USA vs. Mexico) Behavioral 27 1 st Law to Weight Balance Calories in = Calories out Energy balance ---If exceed by 150 kcal a day, results in a more than a ((150 calories X 365 days)= 54,750 excess calories in one year; divided by 3500 calories =) 15 pound weight gain in 1 year QUESTION: What can you do to increase your physical activity by 125 calories a day? 28 1 st Law to Weight Balance Leisure Walk for ~ 1 hour (brisk walk 30 minutes) Rake leaves ~30 minutes Garden for ~30 minutes Lift weights for ~45 minutes The First Law (calories in are equal to calories burned off) does not : Explain controlling how much you eat Help understand genetic influence Explain why women have more fat than men Say where energy is stored (e.g., abdominal fat has more health risks than does fat in your tush) Account for differences in fat depot size 29 30 5
Environmental Factors Breast feeding Infant exposure to mother s tobacco use results in infant increasing fat cells (size and number) Physical exertion and food intake Not the same amount of calories expended through physical activity among all people Bray et al 2003 31 Energy Dense, High Fat Foods QUESTION: What are examples of energy dense (high calorie), high fat foods? Baked goods (Cookies, commercial products like HoHo s, Cup Cakes) Candies Crackers Deep fried foods Yes, including Fry Bread 32 Energy Dense, High Fat Foods Fry Bread is not a traditional food if it contains lard; fry bread is a common contemporary food One serving of fry bread typically has 3 days worth of recommended dietary fat intake) High Fructose Corn Syrup Added to the diet since 1970 s Fructose may affect the body s metabolism not burn off as many calories as compared to someone with a diet that does not have fructose corn syrup Increase consumption in 1980 s corresponds with increase in overweight and obesity 33 34 High Fructose Corn Syrup Higher calories in 2000 probably related to increase per capita consumption of soda from 30 gal/yr to 40 gal/yr Milk consumption decreased during that time High Calcium intake seems to decrease risk of being overweight Portion Control Changes in meal serving sizes between 1980 and 2000 QUESTION: What types of food are high in calcium? 35 6
Portion Size Average number of calories/day in 1980 = 1854 Average number of calories/day in 2000= 2002 148 calories more per day is 15 pounds per year JAMA Jan 2003 Portion Size Increase portion sizes both inside and outside the home: Simply educating the public about which foods to eat and not to eat is not enough, an equally important issue is how much food is being consumed Neilson, Popkin Patterns and Trends in Food Proportion Sizes, 1977-1998 JAMA Vol 289 no 4 pp. 450-453 Jan 2003 Nutrition, Physical Activity (], Prevention, Early Detection, Health Navigators Native American Cancer Research 800-537-8295; http://www.natamcancer.org 37 Neilson, Popkin Patterns and Trends in Food Proportion Sizes, 1977-1998 JAMA Vol 289 no 4 pp. 450-453 Jan 2003 Nutrition, Physical Activity (], Prevention, Early Detection, Health Navigators Native American Cancer Research 800-537-8295; http://www.natamcancer.org 38 Do You Know How Food Portions Have Changed in 20 Years? National Heart, Lung, and Blood Institute Obesity Education Initiative Rick Clark, NACR, modified many of the slides for AIANs Nutrition, Physical Activity (], Prevention, Early Detection, Health Navigators Native American Cancer Research 800-537-8295; http://www.natamcancer.org 40 QUESTION: What did our AIAN Ancestors Use to Measure a Serving Size? A handful Same basic size as deck of cards and the other items on previous page Portion Control and Weight Loss Recommended Daily Calories for Women: 1000-1200 calories Recommend Daily Calories for Men: 1200-1600 calories Nutrition, Physical Activity (], Prevention, Early Detection, Health Navigators Native American Cancer Research 800-537-8295; http://www.natamcancer.org 41 42 7
Portion Control and Weight Loss Consider meal substitutions But cost a lot and usually require Microwave and electricity issue for some AIANs Liquid or pre-packaged meal can help with calorie control and can teach portion control Also cost a lot Not sold in many AIAN markets 43 Read labels Portion Control 1 bagel today = 4 slices of bread 16 oz. serving of steak vs. recommended size of 3-4 oz. for a serving 44 USDA FOOD PYRAMID Dr. Willet s Pyramid The pyramid is not a carbohydrate freefor-all. Need carbohydrates that are whole grain foods etc. The USDA pyramid oversimplified the message. All carbohydrates are not equal All fats are not bad. Walter Willet MD 2001 slide from Grace Alfonsi, MD, Denver Health Authority, 12-2004 presentation 45 46 AIAN Tailored Pyramid s based on USDA Pyramid Old American Plate NOTE: more than 25 Tailored AIAN Food Pyramids American Cancer Society s New American Plate 47 48 8
Transitional American Plate Better American Plate American Cancer Society s New American Plate American Cancer Society s New American Plate 49 50 New American Plate AIAN Food Commodities Programs can select more fruits and vegetables from the USDA list of potential foods, rather than emphasizing commodity cheese, dried eggs, etc. Dresser s Summary of AIAN Traditional Foods and Contemporary Foods Handout includes excerpt from the NCI Documentation of Cancer Research Needs among American Indians and Alaska Natives 1994 Most of the data in Connie Dresser s Chapters 6, 7, 8 and appendices on Nutrition are still accurate today American Cancer Society s New American Plate 51 52 Strategies for Weight Loss and Maintenance Therapy Combined therapy Reduced Calories Physical Activity Behavioral therapy Pharmacotherapy Surgery Low Fat or Low Carbs? Percent of fat in American diet has decreased from 45% in 1960 to 33% today In South Africa nearly 60% of people are overweight even though the average diet contains about 22% of calories from fat Problem is low fat is interpreted as it s okay to eat as much low fat food as I want = Carbohydrates increase 53 54 9
Additional Take Home Message(s) We need to be traditional again (eat and exercise like our ancestors) Stopping by market to pick up fruit or cleaned vegetables can be Fast Food too Physical Activity To increase the energy (calories) used each day 55 Physical Activity: Elders Facts Lack of exercise and poor dietary habits were the second larges underlying cause of death (smoking was the largest) More than two-thirds of older adults don t do regular physical activity You need to be getting more vitamins and minerals when you do a physical activity program Physical Activity: Elders Facts Although most people don t notice it, they lose 20-40% of their muscle tissue as they get older. Exercise can partly restore muscle and strength Staying physically active is important for feeling better and having high quality life 57 58 How to Figure Out How Vigorous You re Working If you can talk fairly easily while doing the activity, it is probably moderate If you can t carry on a conversation, it is probably vigorous If you sweat while you re doing the activity, it may be vigorous How to Figure Out How Vigorous You re Working If you don t sweat much while you re doing the activity on a cool day, it is probably moderate You may sweat after you re done with the activity and it is still moderate If your muscles feel rubbery, it is probably a vigorous activity 59 60 10
How to Figure Out How Vigorous You re Working If you can t talk while you re exercising, it may be too difficult. (p. 31) If you can sing a song while you re doing the physical activity, it is too easy Waiting for permission to use photo / web site John Two Hawks 61 Physical Activity: Rationale for Inclusion Increases energy expenditure Protects and builds lean body mass Improves psychological factors Reduces risk of morbidity and mortality 62 State Activity Programs: Colorado on the Move Walking programs using pedometers In some states the pedometers are free; In others may be ~$10 63 State Activity Programs: Colorado on the Move Increase steps by 2000/day = 1 mile = about 100 calories (varies) Goal is 10,000 steps per day for health May need more for weight loss (combined with less calories) 64 Exercise and Diet Together Exercise For Maintenance 65 Miller et al, Int J Obes Relat Metab Disod 21(10) 941-7 Kayman et al, Nutr 52(5) 800-7; 1990 66 11
Men who Exercise Regularly Maintain Weight Loss Pavlou et al 1989 Men were put on diets ranging from 420 to 1000 calories All lost weight. Those who exercised lost more But when stopped exercising, they regained the weight while whose who exercised maintained weight loss up to 18 months. Pavlou et al 1989 67 68 Overweight and Fit Lee et al (1998) 69 Behavior Therapy The routine use of behavior therapy strategies to promote diet and physical activity is recommended, as these strategies are helpful in achieving weight loss and weight maintenance. Evidence Category B. 70 All of these techniques are important Self-monitoring (write what you eat and how your exercise each day) = high predictor of success Lessons From Losers Consumers Report 32,000 dieters surveyed 25% lost 10% of their starting body weight and kept it off for more than 1 year Most without drugs or organized programs Many through low carbohydrate/high protein diets rather than low fat diets 71 72 12
Lessons From Losers National Weight Control Registry; 3000 people who have lost at least 30 pounds >1 year Exercise burned an average of 400 calories/day Ate less.on average 1400 calories/day Ate Breakfast Lessons From Losers Generally ate lower fat diets, low on sugar and sweets; high on fruits and vegetables Self-Monitoring (Journal, regular weighing) Longer the weight was off the easier it was to stay off; metabolic rate not slower 73 74 Talk with your provider before you begin a physical activity program Physical examination to make certain undiagnosed problems don t exist Recommendations (e.g., pool exercises for someone with arthritis and also very heavy) Tailor the programs for what is enjoyable to YOU 75 76 Behavioral Strategies It takes most people between 6-12 months for a new behavior to become habit This doesn t make it a permanent behavior. If you go back to earlier habits, the weight will come back on The behavior has to continue for you to continue to be successful with weight maintenance Behavioral Strategies Fit the activities into your daily schedule Choose activities that are within your budget Choose activities you can do correctly and safely Choose activities you are unlikely to get injured or hurt you or your family in other ways 77 78 13
Examples of Behavioral Strategies Journaling (write down activity, foods and drinks, including amounts); Some people like to write down what they were doing or how they were feeling Practiced Jingle Dancing for 35 minutes and felt strong and balanced Takes a LOT of time (e.g., 60 minutes daily for Linda B), but is very helpful to many dieters Examples of Behavioral Strategies Find out what time of the day is most feasible for you to add or increase your physical activity Walking early mornings before it is too hot Walking in the middle of the day so that it is warmer (e.g., winter) Of simple changes integrated into your day 79 80 Examples of Behavioral Strategies Examples of Behavioral Strategies Walking up and down stairs rather than taking the elevator Parking farther away from office where you work Parking far away when you go shopping Standing to work rather than sitting all day long Try to find a type of physical activity that is enjoyable to you Find out if you are better doing your activity alone or with others (e.g., friend, family, class) Avoid eating more just because you exercised 81 82 Examples of Behavioral Strategies Examples of Behavioral Strategies When your schedule makes it impossible for you to do what you planned to do, adapt! Rather than walking 30 minutes at lunch, maybe do 15 minutes in the afternoon and another 15 minutes when you get home Reward yourself in ways that don t sabotage your energy balance program Be willing to change the physical activity if it is becoming dreary or boring no longer fun or something you look forward to Remember the realistic weight loss goals (10% in 6 months) and don t give up 83 84 14
Physical Activity Doesn t have to be a class NOTE: NEAT!!! You still need to: Stretch your muscles before you begin (more important as we age) Drink more water than normal Include variety so that different muscles are worked, strengthened and stretched Physical Activity Needs to Include: Endurance activities that make you breathe harder (walking, bicycling, vacuuming, cutting wood) Strength activities, like lifting stones or logs for ceremonial setting; lifting groceries or children or books Balance exercises help prevent falling, tripping and other accidents (like standing on one leg; holding a pose or stance) 85 86 Physical Activity Needs to Include: Weight Loss Plateau Flexibility exercises are different ways of stretching your muscles to keep them limber and better able to hold your body s organs in place All weight loss therapies plateau Continued treatment will maintain weight Relapse is expected when treatment is stopped 87 88 Devices to Help with Devices to Help with The Body Bugg The Bio Trainer 89 90 15
Devices to Help with Devices to Help with USDA USDA 91 92 Useful Web Sites Acknowledgements www.nhlbi.nih.gov..practical guide www.hsph.harvard.edu/nutrition source up to date and easy to read www.oldwayspt.org.all kinds of pyramids www.aicr.org. New American Plate and a really good easy to read brochure NAASO www.naaso.org--lots of provider ed. Many slides from this presentation were made by the Center for Obesity Research The Committee for Obesity Education at NAASO The practical guide: The clinical guidelines on the identification, evaluation, and treatment of overweight and obesity. NHLBI publication 93 94 16