All - 

Hopefully you've read the NutriZine: Lose Weight, Keep it Off! in which I ask you to reflect on whether you think we clinicians overpromise our clients regarding: what we tell our clients about:

 

           - how much weight they can expect to loose

           - how much weight they need to loose to achieve the health benefits

           - what they'll need to do to keep the lost pounds off for the long haul

 

I'd love to hear your thoughts. Do you think we need to modify our messages about these topics? I do.

 

Stay tuned for part 2 of this NutriZine next week in which I'll share more research and 'food for thought'.

 

Thanks for weighing in,

Hope Warshaw, MMSc, RD, CDE

Nutrition Section Editor, presentdiabetes.com

This is something I have felt very passionate about for a long time!  I wrote my master's thesis on the genetic nature of obesity and it was the easiest thing I have ever done.  The amount of research to prove it is undenyable.  The bottom line is true that when you eat more than you exercise away, you will gain weight and when you eat less than you exercise away, you will lose weight.  HOWEVER, there is a lot more to the reasons we overeat than we currently understand.  There is also a lot more to how much energy we have as well.  When you do not use insulin well, you need more than normal amount of insulin  to keep your blood sugar normal (whether you produce it yourself, whether you take a medicine to stimulate insulin production or whether you inject it)  We know insulin is an anabolic hormone (weight gain hormone)  Insulin turns sugar into triglyceride and then fat.  It also prevents the breakdown of fat to be used for energy.  If you have a normal amount of insulin turning a normal amount of sugar to a normal amount of fat, you will be a normal weight.  BUT, if you have extra insulin keeping your sugar normal, you will have extra insulin turning extra sugar into extra fat leading to weight gain....Unfortunately it then sets up a viscous cycle when weight gain leads to more insulin resistance.  We know that things that make insulin resistance worse such as steroids make a person with the same habits gain weight.  We also know that if we do things to make insulin resistance better (such as metformin), the person with the same behaviors lose weight.  It is true that even small weight loss causes improved insulin resistance (but I claim that it is not the weight loss, it is the behavior that caused the weight loss that  improves insulin resistance)  I make this claim because if you remove the fat surgically or lose it unintentionally such as due to illness, it does not improve insulin resistance.  Also if you drastically reduce intake such as surgical management obesity or using a  very low calorie diet such as a liquid protein diet, needs for insulin drastically reduce before any weight loss occurs.  If the weight is kept off but the behaviors that caused the weight loss stop, insulin resistance gets worse before weight is gained.  Even if someone has more insulin resistance when they are heavy than they are when they are thin, they are still more insulin resistant than someone who was thin in the first place.  There are many hormones that play a factor in hunger including leptin, amylin, GLP1, grelin.  As you lose weight grelin (which causes hunger)  goes up.  People who are insulin resistant are ususally amylin resistant as well.  Lots of things cause hunger.  When you do not use insulin well, sugar that is used for fuel stays in the blood...not getting to the muscles where it can be used, so energy levels are low. So why are there very few patients that can continue to eat less and exercise more??  It is very difficult.  Those that do not have the problem have a difficult time understanding it.  It is easy to place blame.  But just think for a minute, what if a person IS telling you the truth when they say they are trying very hard and they really are putting every effort into it and are still having difficulty losing weight.  Then they come to see their health care provider and told they are lying because if they really were doing this they would be skinny.  Do you think it will make them try harder or just throw in the towel and not go back to their health care provider?  Unfortunately far too many patients take the second choice.  I am a very effective weight loss counselor because rather than focusing on the weight (that they do not have any control over), I focus on the behavior that they do have control over.  I do not even use the scale as a measure,  I look at log books.  I explain to patients that research shows that behavior changes make an average 20-30% difference according to very good studies and at least 60-70% is genetic.  That is why even those who have the best of efforts in those many studies, don't lose more than they do.  That does not mean that I tell them not to worry about weight, but after they have done all they can with diet and exercise (which every one should do) that is all they can do.  I tell them that being big and healthy is better than being skinny and unfit.  The reason it is important to recognize the genetic component of obesity is to provide understanding, not ridicule.  Placing blame is VERY harmful, even if it is their fault.  My mission is to get all health care providers to stop focussing on the weight and start focussing on behavior and realize that you can not tell by the scale how hard someone is trying.  Why then is it increasing?  Everyone is more insulin resistant due to societal changes, some are just more effected by it than others due to their "thrifty"genes that we are identifying more and more.  I will be doing a webinar for AADE in November called "The real reason people overeat" where I will present the data supporting all the claims I have made in this note. In answer to the original question, YES we DO need to change what we tell patients based on the studies presented.

If the problem is primarily genetic, then why did it hardly exist 40 years ago compared to now?  Did our genes change so drastically in less than 50 years?  I think not.  Certainly if the problem is genetic, then it must be an interaction with the environment, including the supersized culture and excess of processed food.  Fat and sugar are more obtainable now than at any time in human history.  A study presented at the 2009 European Congress on Obesity showed by examining the USDA food supply data that the food supply precisely predicted rates of overweight in adults and children over a 30 year period.  The study results are clear: the problem is what we are eating.  There was not even leftover variance to attribute to changes in physical activity.

 

Weight gain and loss boils down to energy balance.  If you decrease intake and/or increase expenditure, you will lose weight.   This is an empirical law of physics.  Is it more difficult for some people due to genetic variation or previous history?  Sure.  Are there fluctuations in the metabolic rate within an individual?  Absolutely, and these are difficult to predict, and we should prep patients to expect it and not get discouraged when it happens.  But any person who PERSISTS with a sufficiently decreased caloric intake and/or increased expenditure WILL lose weight.

 

Time and again, across patients and within individuals, weight loss is successful, but the weight comes back over time.  This is a problem of behavior/psychology -- sustaining what are major lifestyle changes, is seriously difficult.  I do not mean at all that we should "blame the patient", because whatever the problem is, it is very deep in our human nature and nearly universal.  It must be, or two-thirds of us would not be overweight.  How many people are in the gym in January vs. April?  Why is sustaining behavior change SO hard?  What are the barriers to sustaining lifestyle change, and how can we minimize them?  This is where we need more research.  We know how to get people to lose weight; we do not know how how to get people to persist over time with the health behaviors that resulted in the weight loss.

In response to the previous comment, certainly trans fats, highly processed foods, high fructose corn syrup, homones injected into animals to get them to produce more milk, chemicals such as herbicides, fast foods and simply eating fast-on the run, supersizing, high stress among many other things....... make insulin resistance worse and do cause weight gain, which is why it is getting worse (not a change in the genes).  My point is that this is happening to EVERY one in society, not just to those who gain weight.  My point is that the person who gains weight MIGHT not be doing anything more wrong than someone who is thin.  It is also true that if you eat more than you exercise off you will gain weight and if you eat less than you exercise off, you will lose weight.  BUT when your genes and homones make you hungry and low energy, it is very hard to do this for ever. If you are genetically very insulin sensitive, you are not as hungry and have more energy, so having the same societal changes may not cause weight gain.  Sure anyone can fight it for a while, but there will eventually be a breaking point.   If someone if just a little more insulin resistant than normal, perhaps it is realistic to "fix" it with exercise and making better food choices.  But if someone is very insulin resistant, doing those behaviors will help but  may not make them a normal weight.  We can not tell by their weight how hard they are trying.   That is why I focus on the log book rather than the scale.  I want to stress that I am not saying that you should just blame genes and forget it.  I do encourage all the same behavior changes.  But I just think we need to stop placing all the blame as this is VERY demotivating and is very harmful to someone who is trying very hard.

My experience and understanding of the literature is that "trying very hard" is actually effective for most people and can be sustained by most people for about 2 months, starts tapering off by 6 months, and after 12 months, almost no one is trying very hard anymore.  If success depends on sustained effort on the part of a human being -- especially in the face of biological drives and social pressure to the contrary -- the results are problematic.  Also, just because a problem is behavioral or psychological does not mean it is the patient's fault.  We should be able to recognize and acknowledge that a problem is behavioral without blaming and shaming people.  My belief is that we need to focus on understanding and compensating for this nearly universal shortcoming when it comes to sustaining behavior change.  We can also take a top-down approach, focusing on policy change to make the food markets not so completely saturated with simple carbohydrates and fat (though Nabisco, Mars, Kraft, etc. may have something to say about that) and requiring product labels to be more salient and honest.

No argument for the societal fixes (that would help everyone, thin or overweight).  But there are undeniable genetic differences that change the response to the environment from one person to another.  Those that are more genetically insulin resistant will lose some weight just like those that are not as insulin resistant with behavior changes (these changes are difficult for both thin and obese persons to maintain on a long term basis).  But when you are very overweight ,7% of weight lost is just as hard as 7% of weight loss when you are only 7% overweight to start with and are able to make it to goal.  So when a person that weighs 300 reaches 7% weight loss and maintains it (even if they did not make their goal weight) that is just as much of a success as someone who was only 7% overweight and made it to goal.  So back to my original suggestion to focus on the behavior not the weight.  It is the behavior that helps insulin resistance not the weight loss (as evidenced that if you lose weight unintentionally such as due to illness or surgically remove fat, you do not get the metabolic benefits of weight loss)  After gastric bypass, the metabolic benefits of decreasing calories happen before weight loss.  I know many thin people who are eating fast food and not exercising and I know many overweight people who are eating healthy and exercising daily.  Just because one person is more overweight than another does not necessarily mean that they are doing more wrong than someone who is thin.  No matter where you start you can go up or down a little with healthy behavior and it is important to do healthy behavior.  It is just important to realize that you can not tell how hard someone is trying by looking at the scale.

Hope,

Sadly it seems that some clients close their ears as soon as I suggest that their weight loss goal is a bit lofty. I never tell anyone that they can’t or shouldn’t lose 100 or 200 or more pounds because it’s certainly within the realm of possibility. I jump through hoops trying to get them to look at their diet and behaviors in terms of health instead of pounds lost or gained. That’s just not what most people want. I always tell them that any amount of weight loss is beneficial to their health and that we’re not in a race. I will say that I refuse to work with someone who won’t look at the long term picture. One thing that does seem to make an impression on most people is when I tell them that there is no easy way; if there were an easy way, there would be no overweight people; and there just isn’t a secret to weight loss that a dozen or so people keep to themselves. I stress that it’s better to reach their goal in 2 years and learn maintenance techniques than it is to hit their goal weight in 6 months and weigh more than they do now in a couple of years. It seems that a lot of people can relate to that, but others just want it now. You know, that’s just part of our culture. We want it now, big, fast and cheap. Thus, the popularity of fast food.

 

You ask if we over promise. I don’t think that most registered dietitians do that. I think we see that in mass marketed diet programs and weight loss books. That over promising is what makes it hard on the rest of us.

 

I work in research. A lot of our studies are for investigational weight loss drugs. We always ask potential subjects how they feel about the possibility of being randomized to placebo. Do they understand that they are expected to work hard whether they get the active the drug or the placebo? Do they understand that the drug might not even work? Even though we ask these questions and stress that no drug offers a solution, we still have people who drop out or complain because “the drug doesn’t work,” “shouldn’t the drug have made me lose more weight by now?” It’s frustrating for us, but I can understand why our patients think this way. It’s because of what they hear in the media, in advertisements and from their friends. I just wish that I had a solution.

 

This is a great discussion. I think it is essential that highly insulin resistant people understand the challenges that the insulin resistance plays on the weight loss. For example, when my daughter went through puberty, she gained a lot of weight. After some time, we discovered that she has PCOS (polycystic ovary syndrome). Prior to this diagnosis, she and I went to weight watchers together. We both ate the same. At the end of the first week, I had lost 4-5 pounds and she lost 1/4 of a pound. It is very hard to stay motivated with those kind of results. And I think that minimal to no weight loss is the major issue for many overweight people. They want to see the results of their healthy lifestyle choices, not only in their labwork, but also on the scales. Even if we don't preach the importance of the weight, society lets them know loud and clear. So I am glad to see that you are doing this research. Hopefully, it will lead to treatments that can address this issue of insulin resistance and poor weight loss. Roxy

All -

Really pleased to see this dynamic discussion going on. A lot of excellent points being made by you all. I will be linking to this discussion this week in my NutriZine part 2 on this topic - so thanks for all your comments. Hopefully there will be many more.

 

By the way, today 2/9 marks the day that Michelle Obama formally annouces her Let's Move, childhood obesity prevention initiative http://obamafoodorama.blogspot.com/2010/02/big-day-at-white-house-for-launch-of.html . There's lots of news coverage about this today. Should get good coverage because there's not much other news going on at the moment b/c most Federal workers are off work due to the DC snow storm and awaiting the next one.

 

For more on Michelle Obama's campaign: www.letsmove.gov.

 

Thanks again,

Hope Warshaw, MMSc, RD, CDE

Nutrition Section Editor, www.presentdiabetes.com

 

I think this is a great discussion. I want to point out what I am seeing in my practice and my personal experience. I have seen many more women telling their doctor they would like to see a dietitian for weight loss. They seem to be more realistic about what it really takes to lose weight than in years past. I do not focus on the scale either but many do want to check their weight. Almost always they notice their clothes size dropping before the scale changes much. I agree the most difficult part is maintaining, and a big part of that I think is not being able to consistently stay active, or realizing how inactive we really are as a society. I struggle with exercising consistently also. LIfe demands interfere and we get off track. I have a high risk for diabetes but have managed to prevent it for 15 years now after GDM. After age 40 and menopause symptoms started though, I gain weight much easier and find I need to work harder to get my waistline to shrink.  There is so much unknown about how our hormones affect diabetes and weight.  Great discussion!

Karen, regarding your comment about getting people to realize how inactive they are, this is a big problem. I see patients frequently who believe they are active because they are busy. It seems quite common to confuse being busy with being physically active. A really good pedometer (not one that adds 20 steps for every bump on the highway) helps people open their eyes. Another problem is that people compare themselves to others. I’ve had several patients tell me that they are very active because they walk one to two miles a couple times per week. To them, that’s a lot because it’s so much more than their friends or coworkers are doing. In addition to pedometers and activity logs, what tools are others using?

I, like so many others, spend most of my day sitting in front of the computer except when I am just standing to teach a class. One of the RDs started a walkers group for employees. She developed an excel program and put it on a shared drive on the computer. There is a walking path around the facility and we each log how many times we walk around the paraemeter on the excel spreadsheet. We are encouraged to use our 15 min. breaks to walk. The RD also sends out weekly motivation e-mails. I personally put the walking in on my calendar. I think that has really helped keep the importance of exercise at the forefront. Even though I only walk 15 min. at a time, it makes me feel better and much more alert. I think I am more efficient after a walk. Roxy

I encourage my clients to find something fun, social, and active to do to increase physical activity. For example, several clients joined a linedancing group, some enjoy playing group sports, ballroom dancing has really taken off in some areas, older folks often enjoy Bone Builders exercise groups, and there are even groups for women pushing their little ones in strollers! Combining a social outing with some type of activity that gets us moving but doesn't seem like the gerbil in their cage type of atmosphere you can get from endlessly running on a treadmill is often extremely motivating.

All -

I encourage you to read the just published Part 2 of this topic - Lose Weight Keep it off!

 

Please share your thoughts and learnings.

 

Link to Part 1: Lose Weight, Keep it Off! Do We Overpromise? Should We Modify Our Messsages?

 

Thanks,

Hope Warshaw, MMSc, RD, CDE

Nutrition Section Editor, www.presentdiabetes.com

Thank you for both articles and your succinct description of the energy gap. We have used this concept in our obesity treatment program for over 20 years to help patients understand the need for maintaining an overall calorie-reduced intake to maintain any weight-loss long term. Helping people to achieve a healthy lifestyle and make the long-term dietary changes necessary for successful maintenance is a cornerstone of the HMR program. Once their weight-loss is achieved, we encourage them to accommodate the energy gap by shifting their diet to higher-volume lower-calorie foods such as vegetables and fruits and the continued strategic use of meal replacements. Both of these approaches are evidence based and have resulted in successful long-term weight loss maintenance by a large percentage of our patients.[i]

 

Your perspective about the need for obesity prevention is an important one that all health care professionals need to emphasize in our patient encounters. Leading a healthy lifestyle to begin with, by being role models ourselves, is also part of that process. Small changes in lifestyle to increase daiily activity as well as using more vegetables and fruits in our daily meal planning are are of the overall public health message of obesity prevention and part of the solution to the energy gap. This is clearly where we as HC professional can assist individuals in their efforts, identifying the tools that will assist them in their goals. I look forward to additional comments from others about your article.

---

I think it is a wonderful thing that  Mrs Obama is focusing on the childhood obesity problem. Living in New York City, I am aware of the cultural influences affecting people whose body mass index indicates obesity and above. Some cultures admire what we call obese bodies since they consider that to be beauty or an indication of affluence. I have personally witness profound changes in some members of such ethnic populations when they receive dietary instruction related to good health and glycemic control. Often they were never enlightened that their usual ethnic eating patterns were less than optimal for health, and they made changes in choices of food and the type and use of fats in their diet. There was a study reported by Med IQ 2007 that on diagnosis of diabetes, the following health problems were identified in children; Hypertension 20-32%,Microalbuminuria 14-22%,•Retinopathy 10%,Dyslipidemia 18-83%,Psychiatric disorders, and especially depression 20%. That is scary for sure. I am happy that there will be someone in the white house promoting healthy lifestyles for our children. Policies to promote this initiative are more possible with such support.

 

Hope, thanks for your interesting Nutrizines and the responses it has evoked. 

Weight management work is often very frustrating.  I tell patients that they can control their behaviors but they can't always control what the scale is going to do.  I like to help them find other measures of success in addition to weight changes.  It is often difficult to have patients buy into this.

More emphasis needs to be placed on prevention, as once obesity occurs, long term success at weight management is so limited.  

Carol

I find at the beginning of weight loss programs, the participants all focus on weekly weight loss. Then as we get closer to the end of the programs, they become concerned about how they are going to maintain the weight they've lost.

What strategies do you find most helpful for people to avoid regaining weight? How can we best discuss energy gap with our clients to help them utilize this information in their lives?

To prevent weight gain, one tactic I've learned that is very helpful is to....encourage people to weigh themselves. This takes work for many, just to get over getting on a scale, but nevertheless, there are too many patients I've met that have lost weight, stopped weighing themselves, only to be surprised at how much weight they have unknowingly gained back. If people are in the midst of losing weight, I teach to weigh themselves on Friday and Monday mornings. I ask them not to freak out if they haven't lost, but at least they'll be on top of things if the scale does start going the other way, and hopefully can assess if there is a reason, and if so, change that. If not, it's time for us to talk. Sometimes just doing the food log is extremely helpful to get things going.

 

If they have reached their goal, I ask them decide a five pound range to stay within. For example if the person is at goal at 150 pounds, their range would be 148 to 153, or 145 to 150. I then ask them to weigh every morning, same time, same scale, etc, preferably right after waking up and urinating, with no clothes on. I explain that their weight will most likely vary from day to day, and that if in fact they are gaining weight, they will catch it early, and hopefully do something about it. I also teach that if their weight is on the lower side of their range, then they have some leeway in their food and movement that day, if on the higher side, it's time to tighten things up. I've seen great success with this.

 

Thanks for all your comments. Great stuff!

EnJOY!

Joy

I agree with everything you said, Joy. We are on the same wavelength as I often use the same approach. In addition, I have found that it is essential to use a reliable digital scale, like Omron's, to assess weight as it gives ounces as well as pounds. This is great for efforts to lose weight because if you at least lost 1/2 pound it will show up on the digital and be encouraging. On the scales with the dials you can't really tell that you lost anything if the weight loss is slow.
I also find that the use of a pedometer is a great support and encourages physical activity. Help patients set a realistic goal, and they can track it each day to be sure they have enough steps. I like the Omron pedometer because it tracks not only regular steps, but aerobic steps and it resets itself at midnight. To my chagrin, I found that there are many inaccurate pedometers on the market. Last year, I bought the Weight Watchers pedometer, and found that it was so sensitive, it gave me credit for twice the amount of steps that the Omron gave me. I was clocking 24,000 steps on weight watchers, and Omron was giving me 12,000 steps.  When I called Weight Watchers, they admitted their pedometer was "very sensitive" and were happy to give me a refund.

I appreciate hearing the strategies that help your clients maintain a healthier, lower weight. I know that the research supports regular weigh-ins as one important strategy, but this doesn't work for everyone. I have several clients who just can't get around the feeling that if they gain weight, even a few ounces, they are 'bad' - which often leads them to emotional eating. On the other hand, if they lose a bit of weight, then they're 'good' and celebrate with eating. The scale becomes the evaluator of not only their weight, but also of who they are as a person. For these clients, I tell them to get rid of the scale completely, and to stop weighing themselves. We then brainstorm other ways of monitoring their weight, and at the same time work on overcoming the feeling that they are 'bad' or 'good' depending on their weight. I'd love to hear more tips about ways to maintain weight loss without using the scale - love the pedometer idea! 

I came back to respond to some of my friend and colleague, Laurie's comments, and was happy to see Pat's response. Yes, I recommend the Omron HJ-112 to most all of my patients. There's nothing so frustrating as to wear one that doesn't work. I use the brand name and number so people get the right one. They make a downloadable one too, HJ-720ITC, I don't usually recommend that one because most of my clients don't want to download, etc, they just need to be motivated to move more. This does it for many. Yes, I used to be an official spokesperson for Omron, but that's not why I recommend this pedometer, I recommend it because it works.  I wear it myself. Thank you Pat.

 

And Laurie, it was great to hear from you and read your comments. I totally agree, there are some people who will not, can not lose weight. For many that come to me for that purpose, I'm very clear to let them know it's really about health, and there's no weight loss guarantee. I talk about making changes for the right reasons and in time we'll tell.

 

Great discussion. Learning lots from you and always great to see friends and make friend online.

 

EnJOY!

joy

 

 

Joy,
Thanks for your support.  Just a little clarification.  I think most people will change weight to some degree with behavior changes.  My point is that I think the studies presented by Hope show us that even with the best of support and effort, behavior changes can realistically only do a certain amount.  Sure you can fight the very strong biological desires for a while  if you are on "The Biggest Loser" and all you do all day long is be chased around by Bob and Jullian and you have many eyes of the nation looking at you.  But that is just not realistic in the real world at least not on the long term.  Making people believe that it is realistic is what is causing some of what the others were talking about then they say they are having a hard time trying to convince people to set realistic goals.  People hear it all day long from media as well as health care providers that all they have to do is put down the fork and get off the couch and they will be 120#.  Even if one person does tell them that is not realistic, they do not believe it.  Until we as heatlh care educators really get it and are consistent when we address others, we will have difficutly convincing them.  That is why it is sooooo important to me to keep trying to get this info out there.  If someone is maintaining a 100# weight loss, but is still 250#, that is every bit as much of a success as someone who was 250 to start with and is now 150.  If someone has always done healthy behaviors and never gained or lost weight and weighs 250 (but would be 350 if they weren't doing the healthy behavior) that is just as much of a success!

My point once again is that you can not tell by a scale how hard someone is trying.  Just because they are overweight, that does not necessarily mean that they are doing anything wrong.  We need to focus on the behavior and the pedometer is an excellent example!  I don't usually recommend one brand over another, but I agree that the Omron is the best one I have used.  I agree with you that for some, weighing daily can be a way to keep things in check, but It is an individual thing.  But for some, especially when it is used as a measure of success, it can cause a lot of harm.   When I help others with weight loss, they are more successful when they realize that the scale is not the measure of success. Due to society and ALOT of health care providers telling them otherwise,  I also have one heck of a time convincing them of that.  It takes a lot of effort.  When someone loses the 20-30 lbs and then levels off, it is especially important to again remind them that this is a huge success.  Most of the time they think they are a failure when they stop losing, get frustrated with the unrealistic goals and stop trying.  Due to what they have heard time and time again, they think they must be doing something wrong and find all kinds of things to blame it on.  If we were to focus on the behavior, and they realize the realistic goals, and how much of a success that 20-30 is, this sets up a positive rather than negative support.  This is much more successful for maintaining the behavior changes which can be greatly beneficial with or without weight loss. 

By the way, stress management helps with insulin resistance and therefore weight loss and can not be forgotten, so I hope you are are still doing your "Laugh it off"  program.  Getting good sleep is another mechanism for improving insulin resistance/weight management.

I encourage my patients to weigh less frequently  rather than more frequently.  I tell them that I don't want that piece of equipment to determine what kind of day it is going to be.  Focusing on healthy behavior changes (increased physical activity, eating high in fiber, mindful eating, selecting foods low in saturated fat) are things the patient can control.  When they use the scale to determine their success, I find they often start to engage in unhealthy behaviors or they abandon some of the positive things they have been doing for themselves.

Carol

Hi Folks:

So, I'm wondering if anyone is using genetic testing for determination of what meal planning approach is best to use for individuals...is anyone familiar with this companies work?

http://www.ilgenetics.com/content/products-services/inherent-health/weight-management.jsp

I have two patients that I've used Inherent Health genetic testing with.  I got the results for one of them and should get the second one any day so it's too soon to give any feedback yet.  I'll keep you posted.

Carol

Laurie, I agree with everything you are saying.

 

Yes, we're still doing Laugh It Off! Thanks for asking. We'd love to come back to St. Louis!  And yes, sleep is so important. I just wrote an article on 7 Things you need to know about weight management, from studies and experts. Of course getting enough sleep, and good quality sleep was one of them. Another important behavior.

 

Thanks so much for your great work on this.

EnJOY!

Joy

I have really enjoyed this thread. Great information. I think gaining understanding this subject of weight loss is essential, but it is also complex and mysterious. I would love to read your article Joy. Where can I find it? Roxy

Bravo, Pat.  I couldn't agree more.

All -

I'm delighted with this wonderful thread of conversation I started. Many excellent points and great dialog. I thought I'd chime in with a few thoughts that I pick up from the thread and some reactions and potential resources:

 

- I noted in the intro to the first NutriZine on this topic that I'm a facilitator for an online, chat research-based 24 wk wt management program Vtrim (www.uvm.edu/vtrim). Last night my group was chatting and as Lynn Grieger noted above (Lynn is also a Vtrim facilitator) my group is just over half way thru and they're getting nervous about "what's maintenance like." I realize in listening (I mean reading their posts) to them that as much as we are consistently chatting about permanent lifestyle change for wt maintenance it is so hard to accept the need for this reality and so hard for people to get away from the on/off diet mentality. We've got work to do!

 

- Re exercise and weight loss. I think it's important to remember that the data on weight loss points to the fact that food choices, fewer cals, less fat is what plays the most critical role in how much weight is lost. Exercise can provide moderate assistance. This paper from the DPP reinforced this point with the 3 year initial DPP program:  Hamman, et al. Diabetes Care, 29(9): 2008. I believe they characterise the cal/fat component of a wt loss plan as the "best actor" and exercise as playing "best supporting actor/role" - this concept of best actor, best supporting role stuck with me and might be a good teaching concept.

 

- Christine Weithman, MS, RD, who has worked with the HMR program many years spoke of the role meal replacements can play in both weight loss and weight maintenance. I encourage people to review two excellent lectures on PRESENTdiabetes.com Nutrition by Linda Delahanty, MS, RD, and RD involved in the DPP study at Mass General. Meal replacements played a role in the DPP trial and are now playing a big role in the LookAHEAD trial. Linda provides an excellent review of the literature to date and how people can utilize meal replacements.

- For successful weight maintenace information/learnings, I think there is no better than the National Weight Control Registry (www.nwcr.ws). This is the registry run by James Hill, PhD and Rena Wing, PhD. There are a number of factors culled from thousands of people who have lost significant weight and kept it off about what has lead to their success. Another resource are the books written for consumers by Anne Fletcher, MS, RD - Thin for Life - again lessons from people who have lost weight and kept it off. Her book Weight Loss Confidential is about teens efforts at weight loss/maintenance.  

 

Let's keep chatting....this is such an important topic and I'm rewarded that it has struck a cord with my colleagues.

 

Hope Warshaw, MMSc, RD, CDE

Nutrition Section, Editor

Hello All,

this thread has been quite interesting and educational.   I'm an RN, NP, CDE not a RD, so I don't do weight loss counseling in general but usually refer those patients to one of you RDs.  I do however do some general dietary counseling vis a vis diabetes management.

One of the tools, I use the most is a detailed log.  I ask patients with Type 2 diabetes to do pre- and 2 hr post meal blood glucose pairs, and record exactly what they ate,  how they  were feeling, and what they are doing activity wise.  Patients immediately begin to understand the relationship between what is going into their mouths and what their glucose values are.   This isn't about judging, Lynn, it's about people taking responsibility and understanding the relationship between food and glucose, and food and feelings, and food and exercise.  Ultimately, it's about choice(s).

I think there is value to all of your approaches, and most importantly, to individualizing the regimen that works for any specific patient, whether it includes a scale, a pedometer, or a log book.

I look forward to continued learning and have downloaded Hope's articles, and would love to have yours also, Joy.

I couldn't agree with Donna more!  I also have found this thread very informative and educational.  For patients that are new to our center we give them a pedometer.  Nothing fancy, and its fairly accurate (I did my own little test on a treadmill to see how accurate it was) and what I found is that, accurate or not, it got people moving.  Even without a very sophisticated, super accurate pedometer our little cheap pedometer got people moving and encouraged them that the next day they could walk even farther!  It was a huge help to get them started! 

Judy, I'm actually very particular about my pedometers. I've found that a pedometer that is over sensitive frequently has two effects that I don't like. Either it convinces my inactive patients that they are more active than they really are, or they frustrate the more savvy ones who know that they didn't walk 800 steps on their commute to work or 30 steps when they changed their pants. Many pedometers work well counting steps on the treadmill or on a walk outside, but they may also record steps that were really speed bumps or anything else that jostles the clothing.

 

Over the years working in research, the sponsors have provided various pedometers for our study subjects. The cheap or inaccurate ones do little good, but the high quality pedometers encourage, inspire and motivate people. I especially love the ones with a 7-day memory, so we can review it together when patients come in. It's a great tool to help structure a conversation about physical activity. These days I never recommend anything other than an Omron.

Hear, hear Jill on the Omron pedometer.  It's the best one I've found also, and amazingly accurate. 

I absolutely agree also. I only use and recommend Omron pedometers

At least partially based on this discussion, I talked with three clients today about using a pedometer to help increase their daily activity and track their progress. One was told by her PCP to get 40 minutes of exercise each day - she strated crying because she works three jobs and can barely find time to sleep 5 hours per night. When I mentioned wearing a pedometer, her face lit up. This is something she can do, and feel good about, without adding more 'shoulds' to her day.

Thanks for the reminder about the value of pedometers!

Hi all
Can you let me know wher I can get Omron Pedometers,if posible free of charge ,for patients that we treat in a city hospital(Queens Hospital Center).in New-York.

I order mine from the website http://www.omronwebstore.com/products/pedometers/pocket_pedometers
I pay full price that way. Joy Pape would probably be the best one to ask about getting some free ones for your patients. Maybe you could have a lending program for them or maybe get a special discount price

I'm not aware of stores that carry Omron pedometers. For a short time, our local Wal Mart had them in their pharmacy area. Perhaps other pharmacies carry them. I have always had to order them. I suspect free will be tough unless you can apply for a grant that will pay for them. The prices vary quite a bit. I've seen them on the Internet from $22 up to $35 or $38. Perhaps you can contact the company directly to see what kind of deals they can offer. Good luck and please share what you learn.

Thank you for the information.

I can totally appreciate all of my peers who are particular about  pedometers but I do not work in an enviroment or demographic where I could tell a patient to go out and buy a $20-40 pedometer (most of our patients cannot even afford their co-pays) or, even entertain the idea that the hospital would buy a bunch for us so I could give some out for free (if I give out one free one then everyone wants one). I appreciate the fact, and am fully aware of the fact that the pedometers we give out are not completely accurate but the point is that it got people moving.  People who never left their couch (self admittedly) now went outside and walked around the block a few times or utilized the track at the local high school and walked around a few times.  I wasn't expecting them to train for the 2012 summer olympics with their pedometer so that they could show me their past walking history for 7 days, I just wanted to see them MOVE, and they did, and they lost a little weight and THAT motivated them.  So I really dont think my idea of a cheap pedometer is so far fetched.  We all want the same things for our patients, for them to live well with the diagnosis they have been given.  How we inspire them and educate them may be conventional or unconventional and if it got them off the couch then that was helping them meet that goal! Thanks!

You do have a point, Judy

And a good one.

thanks for reminding us that we need to meet our patients in their territory. I just read in our local newspaper how there are no MDs accepting new Medicaid or Medicare clients in a local community because the reimbursement isn't enough. So if folks can't even find a PCP, how can we expect them to take care of their diabetes? I'm going to start a new discussion topic on this - does anyone turn away folks with Medicaid or Medicare, and if so - how do you decide to do this?

You have brought up a very important problem, Lyn.  With all the talk about diabetes being a priority health problem, the reimbursement at the caregiver level is less than optimal.  It seems much of th hype about diabetes is for increased research funding, or more money going to administrators. It would be most beneficial if CDE's could be reimbursed directly for diabetes Self Management Education. The Diabetes educators  could recommend to the PCP a change of therapeutic approach after meeting individually with the person with diabetes. PCP's do not have the time to spend with diabetes patients. That, as we know, is why there are Certified Diabetes Educators.

Diabetes is, after all, a self-management condition.  If people do not know the specifics of self management for their individual lifestyle, they will very likely not achieve glycemic control. AADE is forging ahead with advocacy for CDE reimbursement.

In New York City, where I live, people always have the option of going to a New York City hospital for diabetes care. They will take anyone with or without insurance. I know that is not the case in many other areas of the country

Patricia, when you say that people can go to one of the city hospitals for care, does this also include seeing a PCP or just emergency care? Our local hospital of course accepts anyone for an emergency; it's the day-to-day care by a PCP that is becoming less available.

The major medical center in which I work is physically based in periphery of New York City.  I am quite literally seeing 5 patient every week who are admitted through our Emergency Department for daibetes care because they've run out of insulin and are in DKA, or they can't afford their prescriptions and know the hospital will give them a few days of meds when they are discharged.

It is frightening!   I've actually had to have providers write for NPH and Regular insulin because of how significantly cheaper they are than the analog insulins we'd all like to see our insulin-requiring patients use.  The meter I give out is based on which one I have the most strips for.  Thank God for companies like Becton Dickinson.

None of the companies that have the $4.00 medicine program, include insulin in this.  So, we're left having to put patients on oral agents that they should not longer be using (one patient actually had an A1c of 22.0% but couldn't afford the insulin, so got $4 metformin.  Hospitals are not legally permitted to give out insulin samples.  My patients can't afford the co-pay to see the endocrine people who are off site, and able to dispense insulin samples.  Our clinics are based here in the hospital, physically, and thus limited by the same regulations.

It's a nightmare, and some days I just feel like crying over the hardships my patients are enduring, and how awful they feel with their 15%+ A1c values.   One woman told me, she could either eat, or take insulin, but couldn't afford to do both!

It's stories like these that our legislators need to hear. As the health care debate continues, it's imperative that CDEs are part of the discussion and the process. I'm sure that the American Diabetes Association has statistics on the amount of money that we save with diabetes education. Those hard facts combined with personal stories should make a big impact.

The insulin companies do have patient assistance programs that I have used to help people get free insulin. Novo nordisk will even give out pens. BUT the big problem is that the patient does have to have a PCP before they will provide insulin. Roxy

Hope,
You discussed the "energy gap" in your part 2 article. Is this the same thing as the "set point" we used to hear about, regarding body weight?

I always say my patient that losing weight isn't that easy and it can achieved only by combination of diet and exercise. expected weight loss per month is around 4pounds.I belive that  this target can be reached with a reduction of 400-500 calories per day from actual intake along with moderate exercise. it is also found that slow and steady reduction in weight is the healthy way of losing weight and also it prevents increase in weight  immediately after the strict weight lose regimens are completed.

    With Regards,
   uma

Laurie, I truly appreciate your comments/responses about the complexity of the obesity issue.  It is simply not as black and white as eat less/exercise more.  A lot of people can't seem to get beyond that.  True as a society we are more sedate, eating more processed, less nutritious food.  Bottom line as you said is that not just obese people are doing this.  So obesity does have a large genetic component.  A few years ago I  read research on a specific type of bowel bacteria being isolated in obese individuals.  There are recently identifed gut enzymes that impact diabetes, perhaps weight is impacted by unknown enzyme deficiencies.  And who knows what we don't know about absorption and obesity.  People who don't grasp that can become very arrogant about the fact that they don't struggle with obesity because they are so good at eating well and exercising.  We can be too quick to label people as "liars" or "non-compliant"  Our culture is very obsessed with equating health and goodness with being thin and beautiful.  If you are one of those individuals who struggles despite incredible efforts, it takes a lot of internal strength  to move beyond the cultural messages  and maintain self-esteem and focus on being healthy.  They need our support to do this.  This is where health care providers and educators need to focus - our own inner change.  Our job is support an individual on the path to healthy lives, not create perfect appearing physical specimens.  If we don't grasp the complexity, we can actually do more harm than good.