Download DUKE DIET and FITNESS CENTER

The Duke Diet and Fitness Center
Welcomes
DUKE FOOD WORKING GROUP
October 8, 2014
Putting the Pieces Together: An Intensive,
Multidisciplinary Obesity Treatment Model
DUKE DIET and FITNESS CENTER
GUIDING PRINCIPLE: We need to make permanent,
sustainable changes in both food intake and
physical activity to lose weight, maintain weight
loss, and live a healthier lifestyle
DIET and FITNESS CENTER PROGRAMS:
• Residential weight loss program
– New clients
– Return clients
• Optifast
• Outpatient medical, dietary, and behavioral health
consults
• Research
DFC Residential Weight Loss Program
Overview
• One-, two-, three-, and four week programs
• Clients from all over the US (and around the globe) to
Durham- stay in hotels in the area
• Clients spend all day at the DFC
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Building opens at 7AM and closes at 9PM
Three meals daily + snacks (breakfast and lunch Sat and Sun)
Exercise classes
Classroom lectures
Free time for individual exercise, study, etc.
Massage, acupuncture, physical therapy, etc. are available
DFC Clients
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Average age: early 50s
Age range: late teens to nineties
Gender: 60% women, 40% men
Average BMI: 38 kg/sq m
Clients are typically well educated, well
informed, upper socioeconomic status, highly
motivated to make lifestyle changes
DFC Residential Weight Loss Program
Overview
• Four components
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Medical
Nutrition
Fitness
Behavioral Health
• All new clients are assessed by professionals in each component during
first few days
• Each component offers classroom lectures in its area of expertise
• Clients return to professionals in each component throughout their DFC
programs for check in visits, questions, progress reports, etc.
DFC Residential Weight Loss Program
Overview
Weekly Patient Care Conference
• Attended by all DFC Treatment Staff (all members of all
four components plus Patient Advocate)
• Every week each incoming client is presented and
discussed
• Clients who may need special attention or additional
evaluation are identified
• Current clients who are not losing weight, are missing
meals, are not exercising, etc., are also discussed
• Goal is to have every client be successful!
DFC Medical Component
• MD and FNP
• Intensively address all
obesity related
comorbidities
• Serve as Primary Care
Providers for clients
while at the DFC
• Arrange consultations
with Duke specialists
• Lectures
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Overview of Obesity
Diabetes
Hypertension
Lab Interpretation
Preventive Medicine
Osteoarthritis
Weight Loss
Medications/Weight
Loss Surgery
DFC Outpatient Options
• For local residents
• Outpatient consults for weight loss by
– Medical staff
– Nutrition staff
– Behavioral health staff
• Optifast full and partial meal replacement
programs
Putting the Pieces Together:
Nutrition
Developing an Effective, Sustainable
Eating Plan for Long Term Success
The Diet
• 3 meals daily, snacks optional
• Calorie & Portion based
– 1000 – 1500 kcal
• Clients plan their own menu
– Flexible food choices/diet plans
to individualize program
– Gain meal planning skills
– Sustainable, realistic
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Food Service
Meriwether Godsey
• Based in Lynchburg, VA
• Local ingredient sourcing as much as possible
• Fresh, scratch made
• Limit use of disposables
– Recycled/Recyclable or compostable
• Limit food waste
– Prep based on menu tally
– Compost food scraps
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Nutrition Treatment Plan
• Nutrition Staff: 2 Registered
Dietitians (RD/RDN)
• Week one: 1 hr with RD
• Optional weekly check-ins
(15-30 min)
– Monitor progress/tweak
menu
– Answer questions
– Plan for return home
– Weight & dieting history
– Medical concerns r/t
nutrition (diabetes,
cholesterol); meds &
supplements
– Healthy eating barriers
– Typical daily diet
– Calculate RMR, review calorie
prescription
• Support at Home
– Dietitian on Demand
– DFC Blog & Facebook
– Recipe updates
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Common Nutrition Related
Challenges
What?
• Skipping meals
• Lack fruits & veggies
• Frequent restaurant &
processed foods
• Mindless eating
• Emotional eating
• Uncontrolled portions
• Yo-yo & all/nothing dieting
Why?
• Lack of time
• Don’t plan ahead
• “Healthy” foods perceived less
convenient
• Temptation (food environment)
• Lack hunger awareness
• Conflicting nutrition
information
• Low interest or ability to cook
Nutrition Curriculum
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Nutrition Fundamentals
Calories & Portions
Restaurant Strategies
Grocery Shopping
Cooking
Mindful Eating
Mindless Eating
• Meal Planning
• Volumetrics
• Special Topics
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Fish
Heart healthy eating
Power foods
Anti-inflammatory diet
Vitamins & minerals
(Coming soon): Nutrition
myths/controversies
Research/Collaboration Ideas
• Resting Metabolic Rate testing
– Working on IRB proposal
– Prediction Equations, Indirect
Calorimetry, RMR, and Obesity
• Diet comparisons
– Varying diet composition
(macronutrients; processed
foods; artificial sweeteners)
– Effects on gut micro flora
– Long term vs. short term
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Putting the Pieces Together:
Behavioral Health
Building a Bridge Between
Knowledge and Action
From Knowledge to Implementation
I know
what I
should
do…
I just
don’t do
it..
If only I
had
more
time…
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If only I
felt more
motivated
If only…
Behavioral Health Services at DFC
• Initial 50 minute assessment with one of our
clinicians
• Weekly 20-min check in sessions to follow up,
answer questions, prepare for home
• Lectures and Groups
• Individual sessions
• Case management during the program
• Outpatient consultation, psychotherapy, post
bariatric surgery assistance
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Barriers to Healthy Lifestyle Change
• Too many social events with food and drinks
• Emotional eating
• Lack of support (food/exercise police or the
enabler)
• All or nothing mentality
• Unrealistic expectations
• Mood disorders
• Disordered eating (binge eating)
Behavioral Health:
Tool Box for Success
• Make lifestyle change a
priority (time mgmt)
• Self-monitoring and
accountability
• Develop healthy
mindset
• Address
depression/anxiety/grief
• Managing cues in the
environment
• Stress management
• Coping skills for
negative emotions
• Realistic goal setting
• Mindfulness
Examples of Behavioral Health
Lectures
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Overcoming Emotional Eating
Stress Management
Action Planning for Success in the Real World
Controlling Overeating and Binge Eating
Enlisting Social Support
Mindful Awareness Training
Willpower and Skillpower
Group: Looking Deeper at Emotional Eating
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Identify Specific Goals and
Visions
• Build confidence and hope
• Not just weight loss goals, but lifestyle goals
• Focus on desired outcomes, not what “you
don’t want”
Identify Challenges to
Implementation and Focus on
Specific Action to Follow Through
• If I’m tempted to eat when I’m feeling lonely…. Then I will
– Reach out to a friend that can give me support
– I will remind myself of other times I made it through
– I will reach for something healthy
Preparing for Future Challenges
and Set Backs
• Learning from setbacks
• Lifestyle Coaching for ongoing support
• Weekly teleconferences to stay connected with DFC
Putting the Pieces Together:
Fitness
Getting Started in the Right
Direction
Fitness Planning at the Duke DFC
Part 1: Who We Are
FITNESS PROFESSIONALS
(Clinical) Exercise Physiologist
Exercise/Fitness Specialist
Certified Personal Trainer
Recommended for
those requiring exercise
supervision/monitoring
Degrees: Exercise Science/Physiology, Phys Ed/Adult Fitness, Wellness,
Health & Human Performance
Certifying Organizations
• ACSM (American College of Sports Medicine)
• NSCA (National Strength and Conditioning Association)
• NASM (National Academy of Sports Medicine)
• ACE (American Council on Exercise)
• Physical Mind Institute, Stott Pilates, etc
Part 2 : What We Believe
OUR PHILOSOPHY
The guiding principles
 Exercise & consistent PA are essential to weight control,
disease prevention and a healthy lifestyle.
 Learn to exercise effectively, safely and successfully. Add
more movement to daily life. Create a schedule that fits “your
lifestyle”.
 Greater focus on PA & benefits of aerobic, strength, and
flexibility exercise.
 Find who “you” are as an exerciser, explore new ideas,
practice what you can/will do at home.
Part 3 : What We Do
FITNESS PROFESSIONAL’S ROLE
• Pre-exercise clearance (including motivation)
– Stress test
– Orthopedic/PT consults
• Fitness Assessment
• Develop relationship with patient
• Guide/Coach patients through planning process for
exercise at home
• Goal Setting for home
Typical DFC Fitness Assessment
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Review Medical History (CAD, HTN, DM)
Orthopedic Limitations/Concerns
Current PA level (last 3 months) & Past Exercise History
PA Barriers (internal & external)
Initial Action Plan for home
Physical Activity Goals (not weight loss goals!)
Exercise Prescription: Frequency, Intensity, Time, Type
– At what level/environment will patient succeed
(@DFC/@home)?
– Should patient work independently? With Physical Therapy?
Common Orthopedic Concerns
and Recommendations
KNEE
LOW BACK
HIP
OA Bursitis
Rotator Cuff
Bursitis
OA
Meniscus
Tendonitis
OA
Sciatica
Disc Injury
 Quad strength
 Core strength/
stability
 Flexibility of quads,
hamstrings, hips, IT
band
 Core strength/
stability
 Flexibility of low
back, hips,
hamstrings
 Abductor/Adductor
strength
 Core
strength/stability
 Internal/External
rotation
Weight loss typically leads
to some level of
improvement of many orthopedic issues.
Physical Activity & Motivation
Stage of Change
Action
Precontemplation
 Not ready to exercise
Encourage patient to consider exercising; tell patient
about health benefits of exercise.
Contemplation
 Interested in/thinking
about exercise
Independent
Supervision Necessary
Write Rx; refer to nonclinical professional
Refer to clinical exercise
professional
Preparation
Write Rx; refer to non Exercising less than
clinical professional
recommended amount
Refer to clinical exercise
professional
Action & Maintenance
Encourage continued
 Exercising
exercise
recommended amount
Refer to clinical exercise
professional
www.ExerciseIsMedicine.org
Physical Activity & Health Guidelines
30 min moderate-intensity cardio; 5 days/wk
-OR20 min vigorous-intensity cardio; 3 days/wk
ACSM/AHA
Is this optimal for weight loss and/or maintenance?
Weight management guidelines:
60 minutes moderate intensity
activity most days
INSTITUTE OF MEDICINE
EXERCISE GUIDELINES FOR
WEIGHT MANAGEMENT
Frequency
Intensity
Time
Type
Aerobic
4-6 days/wk
50-85% HRR
60-85% HRmax
11-14 RPE
Accumulated
30-60 mins/day
200-300 mins/wk
Large muscles,
rhythmic,
continuous
Strength
2-3 days/wk
Non-consecutive
Volitional
fatigue. Final 2-3
reps should be
challenging
1-3 sets
8-15 reps
20-45 minutes
8-10 exercises;
include all
major muscle
groups
Flexibility
2-3 days/wk
Point of mild
discomfort, but
not pain
15-30 seconds
each stretch;
2-4x/stretch
Static
stretching
Challenge
appropriate to
the individual
>60 mins/wk
Balance,
coordination,
gait, agility
minimum
Neuromotor
“Functional”
>2-3 days/wk
Activities of
Daily Living
(ADLs)
Use pedometer to establish baseline # of steps; gradually increase toward
average of 10,000 steps/day.
Class Offerings – Activity & Lecture
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Aqua Aerobics/Aqua Force
Cardio Interval / Circuit
Step / Kickboxing
Chair Aerobics
Pilates
Strength, Balance & Stretch
Gyrokinesis
Boot Camp
Restorative Strength (Yoga,
Foam Rollers, Pilates)
• Fitness Fundamentals
• Exercise Metabolism
• Getting FIT with
Technology
• Components of Fitness
(Strength & Flexibility)
• Making Peace with
Exercise
• Whats Wrong with My
Back? Knee? Shoulder?
EXERCISE GUIDELINES FOR
WEIGHT MANAGEMENT
Recommended Activities
Aerobic
Walking (treadmills/outdoor), biking, elliptical, NuStep, group fitness
classes (land & aquatic), swimming
Strength
Machine circuit, free weights, resistance bands/tubes, bodyweight,
medicine balls, stability balls, water resistance, kettlebells, TRX, BOSU
Flexibility
Stretching, yoga, Pilates, Tai Chi, foam rollers, gyrokinesis
Neuromotor
“Functional”
Balance discs, BOSU, balance mats/beams, tandem stance/walk,
strength exercises combined with balance, Tai Chi, yoga, TRX
ADLs
Stairs, short walk breaks at work, park car farther away, housework,
yardwork
Sports &
Recreation
Tennis, golf, hiking, dancing, kayaking, bowling, Wii
Intervention
• Physical activity goal setting (not weight loss goals!)
• Tracking
– Garmin Vivofit, FitBit, journal, pedometer, smartphone apps
• Positive support
• BodPod testing
• Educating clients for accurate metabolic expectations
Lack of activity destroys the good condition of every human being, while
movement and methodical physical exercise save it and preserve it.
Q&A
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