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Nutrition
The Registered Dietitian; Laying the Foundation for Dietary Change
In a multidisciplinary approach to obesity treatment, the primary role of the registered dietitian (RD) is to guide the patient toward simple, effective strategies to improve their diet quality and decrease overall energy intake. Confusion about food and diet is widespread, however, there are several simple strategies patients can use to reduce energy intake without inducing feelings of hunger than can lead to binge eating.Eating less. Over the past 30 years, the mean daily energy intake of Americans has increased from 2,450kcal to 2,618kcal for men and from 1,542kcal to 1,877kcal for women.10 Larger food portions are a primary contributor to higher energy intake, and consequently, the rise in obesity prevalence.11 Data indicate that the more food is served, the more people eat. When counseling and educating clients, food and nutrition professionals must consider that the portion sizes of foods sold in the marketplace may have considerable influence on the portion sizes that individuals view as typical and appropriate to consume on a single eating occasion.13 RDs can help patients eat less by teaching them to leave a little food behind at each meal—a realistic and achievable goal. Eating better. Effective weight loss education must include strategies to not only eat less, but to also eat better. Lower fat, whole foods (i.e., fruits, vegetables, legumes, and whole grains) can help patients reduce overall intake and increase total nutrient consumption. Fresh produce is particularly high in water, adding weight and volume to increase satiety without adding energy. Evidence shows that subjects in a reduced-fat and increased fruit and vegetable group lost 33 percent more weight at six months than those who only decreased their fat intake.21 This is consistent with Ledikwe, et al., who demonstrate that a low-energy-dense diet is associated not only with reduced calorie intake and increased food consumption, but also with higher diet quality than a high-energy-dense diet.
Exercise
The Exercise Specialist: Integrating Physical Activity into a Healthy Lifestyle
Physical activity is an important aspect of any weight loss treatment; the combination of diet and exercise is the most effective behavioral approach to obesity treatment, better than either alone.16 Despite the significant physical and mental benefits associated with regular physical activity, many of those most in need (i.e., the overweight and obese) may perceive it as daunting.17, 18 It is crucial, therefore, for the specialist to clarify the definitions for physical activity and exercise. Physical activity includes any movement involving contractions of the muscles and energy expenditure, and exercise is a type of physical activity.Non-exercise activity thermogenesis (NEAT), or general lifestyle activity, is an integral part of any weight loss attempt; it can account for a difference of up to a 2,000kcal expenditure per day in active versus sedentary individuals.19 Patients can be encouraged to stand while using the phone, iron while watching television, run errands on foot, take stairs instead of elevators, walk down the hall rather than e-mail a coworker, and so on—the possibilities are endless. Furthermore, studies have shown that lifestyle activity can be as effective as a more structured program in lowering blood pressure and body-fat percentage.20 Where NEAT is concerned, every step counts. Unlike NEAT, which occurs as a result of basic lifestyle, exercise is designed to improve one or several fitness parameters: cardiorespiratory fitness, muscular strength, or balance and flexibility. Walking is one of the most common and convenient exercises. Steps can be accumulated throughout the day as individuals walk in the course of completing tasks (NEAT) and in purposeful, planned exercise. Additionally, though many individuals often assume that physical activity, especially planned exercise, needs to be performed in single bouts, several studies indicate that two or more intermittent bouts of exercise throughout the day produce health benefits equivalent to single, longer periods of exercise.21, 22 Three 10-minute walking sessions can seem far more achievable than a single 30-minute session. The exercise specialist should guide patients toward small, achievable goals, such as adding one minute to a 10-minute walk, climbing one extra flight of stairs on the way to work, or adding 100 steps at a time to a day’s total. Pedometers are one of the most useful tools as individuals increase their physical activity. By increasing physical activity in small increments over time, patients are able to achieve longer-term goals of 10,000 daily steps or 175 minutes of movement/day—without frustration or a sense of failure. The crucial point is that patients should be encouraged to increase their physical activity throughout the day in any way possible, using a variety of lifestyle changes and planned exercises.
Mentally Prepare
The Behavioral Therapist: Mentally Preparing the Patient
Failure to maintain diet and exercise modifications may occur when a patient is not mentally prepared for long-term interventions. Many people participating in a weight loss program for the first time are nervous and afraid, which can promote resistance to change. Behavior therapy provides the mental preparation and structure that can help patients manage obstacles and identify and achieve their goals. Motivational interviewing (MI), a directed, client-centered counseling style developed by Miller and Rollnick, recommends that caregivers roll with resistance. For example, statements demonstrating resistance to change should not be challenged by the clinician, but rather used as momentum to further explore the patient’s views. Using this strategy, behavioral therapists can gently approach the reasons for the resistance to necessary lifestyle changes (e.g., previous failures, lack of time, lack of knowledge, and an unsupportive environment) and address them directly. MI behavior counselors can use this theory to guide clients toward awareness of discrepancies between current behavior (e.g., late-night binging, sedentary lifestyles) and their goals, such as lower weight or increased health. As treatment progresses, individuals learn to work through their resistance on their own, and eventually come to define their own problems and solutions. After the benefits of losing weight have been firmly established, targeted goals must be created. Patients commonly set unrealistic “goal weights,” greatly overestimating the amount of weight they can feasibly lose and maintain; many are unaware that losing only 5 to 10% of initial body weight can significantly decrease the severity of obesity-related risk factors, including hypercholesterolemia, hypertension, and diabetes. Behavioral therapists can use this information to help patients realize the benefits they stand to gain with small, modest weight loss, guiding them toward the much more achievable weight goal of 5 to 10% of their starting body weight. In encouraging individuals to integrate diet and physical activity into their lives, no change is too small—indeed, one change can become the catalyst to successful maintenance of a total lifestyle modification. Small steps, feasible goals, and recognition of their own mental barriers to change are the means by which change occurs.
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