Download The dietitian`s perspective

The dietitian’s
perspective
Paula Mee gives some tips on
setting realistic goals for patients,
including the use of a food and
lifestyle journal
R
eductions in energy consumption of
500-1,000kcal per day should result in
appropriate rates of weight loss in most obese
patients.1 What scientists define as ‘appropriate weight loss’ is 1-2lbs per week. What obese
patients consider as ‘appropriate weight loss’ can
be altogether different. A pound a week is, for
many, an abysmally slow journey to a slimmer
silhouette, and not a sufficient return on their
painstaking efforts to overhaul their ways.
Many patients understand that as their
weight has crept up over a number of years,
they certainly can’t expect any quick fixes. This
does not, however, stop them hankering after an
alternative to changing eating habits they may
have established in childhood, and mustering up
the motivation to set realistic targets and adopting a confident and positive attitude to major
behavioural change.
losing between 5-10% of their baseline weight,
particularly when the excess weight is lost from
the waist.
Many studies have shown that this level of
weight loss is associated with an improvement
in a variety of health outcomes, including an
increase in life expectancy of up to four years in
people with type 2 diabetes. This 5-10% weight
loss equates to a 30% reduction of the dangerous fat around the abdomen, with knock-on
positive effects on cholesterol levels, blood pressure and risk of heart disease.
Looking at Table 1, I usually ask patients to
consider a short-term weight loss goal of 5-10%
and then consider a longer-term goal, to get to
their more comfortable target weight. You’ll still
have the vexed and impatient recoil in degust at
How much weight loss is enough?
In an effort to augment their own personal
and usually appearance-driven reasons for losing
weight, it can sometimes reassure a patient to
know that the scientific evidence shows the most
striking benefit from weight loss comes from
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Table 1
Recommended short-term weight loss goals
Starting weight
5% weight loss is:
10% weight loss is:
70kg (11 stone)
3.5 kg (8lbs)
7kg (1 stone 2lb)
80kg (14 stone)
4.5 kg (10lb)
9kg (1 stone 6lb)
102kg (16 stone)
5kg (11lb)
10kg (1 stone 8lb)
115kg (18 stone)
6kg (13lb)
11.5kg (1 stone 11lb)
127kg (20 stone)
6.5kg (1 stone)
13 kg (2 stone)
Table 2
Weight loss diary
Desired weight loss:
Range of time: I will achieve this by:
3kg (7lb)
3-6 weeks
____________________
6.5 kg (14lb)
7-13 weeks
____________________
13kg (2 stone)
3-6 months
____________________
19kg (3 stone)
5-10 months
____________________
the thought of losing just one stone from their 20
stone frame.
As one patient put it: “what difference will a
stone make to my appearance? Sure you’d never
miss a stone from a mountain, would you?”
Timelines
Setting unrealistic and unachievable longterm goals for weight loss will inevitably lead to
disappointment and revitalise the patient’s quest
for the ‘secret’ to slimming elsewhere. I ask patients to fill in the third column in Table 2 above
with their personal target date based on their
rate of weight loss.
To stay motivated, as with anything in life,
it is important to see results. I give patients a
printed scales record of their weight, BMI and
body fat at each visit, but patients can keep their
own weight records and check their waist circumferences each week. Regularly monitoring and
tracking their progress is very motivating.
Seeing a positive effect on cholesterol
and blood pressure levels can also be a great
reward for their success. For the disconcerted, I
frequently point out the positive changes to their
body fat levels and BMI levels over time.
Asking them to hold a one-kilo plastic model
Planning and monitoring
Before any weight loss programme is started,
patients will find it useful to evaluate their starting position. Using a food and lifestyle journal,
they can identify existing patterns of behaviour
that are unhelpful, examine the quality and quantity of eaten foods, plan strategies to overcome
barriers and monitor their progress.
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Table 3
Weight classification by BMI
BMI, kg/m2
< 18.5
18.5-24.9
25.0-29.9
30.0-34.9
35.0-39.9
> 40.0
Obesity class
Underweight
Normal
Overweight
Obesity
I
II
Extreme obesity
III
Disease risk
Increased
Normal
Increased
High
Very high
Extremely high
and fibre.
Low GI carbohydrates can replace high GI
carbohydrates for better satiety and blood glucose control. Saturated and trans fats should be
replaced with healthier omega-3 and monounsaturated fats. More plant proteins such as peas,
beans and lentils should be encouraged instead
of processed high fat meats.
At least five servings of fruit and veg daily
and two portions of fish a week, at least one
of which is oily, should be encouraged.Energy
intake must fall below energy expenditure, but
not so low that excess lean tissue is lost, hunger
escalates, diet quality declines, and health is
compromised.
The best approach, I find, is to reduce a
patient’s calorie intake by approximately 500kcal
per day, and establish agreed exercise goals
framed around the FITT acronym (F = frequency,
I = intensity, T = type and T = time or duration of
exercise).
On subsequent visits, behaviour can be monitored periodically by means of a food and lifestyle
journal. As the patients self-monitors, awareness
grows and behaviour changes slowly.
Patients can regularly ask themselves: “is
what I’m doing now really helping me to get to
where I want to go?” If the answer is no, the
more difficult question is: “What am I prepared
to do to get to my weight loss target?”
of body fat can help them see that it is no meagre achievement to be down one kilo of body-fat
since their last visit.
The best approach
There are numerous ways to lose weight in
the short-term. In January of this year, scientists
from the Rowett Research Institute in Aberdeen
demonstrated that a high-protein, low-carbohydrate diet was most effective at reducing hunger
and promoting weight loss, at least in the shortterm.2
They found that volunteers on the ketogenic
diet reduced their energy intake without increasing their hunger, and this was a very important
factor in the subjects’ ability to stick to the diet
in the short-term. However, other studies have
shown that while weight loss is significantly
greater in the first three to six months on a highprotein, low-carbohydrate diet than on a low-fat
diet, this difference disappears after one year and
there are no significant differences in weight loss
between the approaches.3
Unfortunately, there are unresolved health
issues related to long-term high-protein diets,
including bowel disorders, osteoporosis and renal
damage. Compliance can also be very poor.
The challenge is to find a long-term, effective
and sustainable approach which will be agreeable
to the patient. A weight loss plan needs to focus
on the quality and quantity of all the macronutrients (fats, proteins and carbohydrates), as well as
ensuring an adequate intake of vitamins, minerals
Weight loss drugs
Dr Rob Andrews from the University of Bristol
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the greater the initial weight loss
• Behavioural therapies (eg. cognitive therapy,
psychotherapy, relaxation therapy, hypnotherapy) produce an average weight loss of 2.3kg
• Exercise plus diet result in an average weight
loss of 10.7kg and helps to maintain weight
loss for a longer period
• Exercise plus diet plus behavioural therapies
result in the greatest average weight loss of
12-15kg
• Taking weight loss drugs with no changes in
lifestyle result in an average weight loss of
5kg. Taking weight loss drugs, in combination
with behavioural therapies, leads to an average
weight loss of 12kg
• Patients who lose more than 10% of their body
weight prior to bariatric surgery are 2.12 times
more likely to achieve a 70% loss of excess
body weight.
If the treatment or cure for obesity was
known, this condition would not have reached
the alarming levels that it has grown to worldwide. Helping patients to understand that being
obese and inactive will lead to disease at some
stage, and that moderate weight loss can bring
about improvements in their general physical and
mental health, is critical if we are to slow the effects of this epidemic.
Since we are too late for the obesity timebomb (it has already exploded), perhaps we can
defuse the inevitable type 2 diabetes and heart
disease time-bombs that are fast approaching. n
Paula Mee, Nutrition Consulting
reviewed the research on how successful different
lifestyle interventions (such as exercise, diet and
behavioural therapies) were in the treatment of
obesity, when carried out alone or in combination
with other treatments such as bariatric surgery
and weight-loss drugs.4
Andrews reported that when weight loss
drugs were given on their own, with no other
changes in lifestyle, they produced an average
weight loss of 5kg, the same amount of weight
you lose if you went on a calorie-controlled diet
and took regular exercise. However, if weight loss
drugs were offered in combination with behavioural therapies, their effectiveness was increased
by over 100% (from 5kg to 12kg average weight
loss).
References
1. Melanson K. Nutrition Review: Dietary Considerations
for Obesity Treatment. American Journal of Lifestyle
Medicine 2007; Vol. 1, No. 6, 433-436
2. Johnstone AM, Horgan GW, Murison SD, Bremner
DM, Lobley GE. Effects of a high-protein ketogenic diet
on hunger, appetite, and weight loss in obese men feeding ad libitum. Am J Clin Nutr. 2008;87(1):44-55
3. Foster GD, Wyatt HR, Hill JO et al. A randomized trial
of a low carbohydrate diet for obesity. New Engl J Med
2003; 348 (21): 2082-90
4. Andrews R. Surgery and drugs alone are not enough
to combat obesity. Presented at the Society for Endocrinology BES meeting, April 2008
Summary points
• Exercise alone produces an average weight
loss of 1.8kg. The more you exercise the more
weight you lose
• Diet alone produces an average weight loss of
5.0kg. This effect peaks 6-12 months following
the start of the diet and wanes after this point.
No diet is better than any other in the longterm, but the greater the reduction in calories,
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