Presentation on theme: "Assessment and Management of Obesity Cheryl A. Gibson, Ph.D. Department of Internal Medicine Susan Carlson, Ph.D. Department of Dietetics and Nutrition."— Presentation transcript:
Assessment and Management of Obesity Cheryl A. Gibson, Ph.D. Department of Internal Medicine Susan Carlson, Ph.D. Department of Dietetics and Nutrition
Objectives Upon completion of this session, you will be able to: –Determine a patient’s level of obesity by calculating the BMI –Assess a patient’s risk status associated with obesity by analyzing the BMI, waist circumference, and co-morbidities –Assess a patient’s readiness to lose weight –Be able to work with a patient to develop a personalized strategy to address their overweight/obesity
Epidemiology: Obesity/Overweight In last 2 decades, prevalence increased by % among adults, and 3-fold among children and adolescents 62% of US pop. are overweight, of these, 30% are obese Higher in specific subgroups –i.e., African American women have an 80% and 50% prevalence of overweight and obesity, respectively 29% of US adults report no regular physical activity
Obesity* Trends Among U.S. Adults BRFSS, 1985 (*BMI 30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%-14% 15-19% 20% Source: BRFSS, CDC.
Obesity* Trends Among U.S. Adults BRFSS, 1986 (*BMI 30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%-14% 15-19% 20% Source: BRFSS, CDC.
Obesity* Trends Among U.S. Adults BRFSS, 1987 (*BMI 30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%-14% 15-19% 20% Source: BRFSS, CDC.
Obesity* Trends Among U.S. Adults BRFSS, 1988 (*BMI 30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%-14% 15-19% 20% Source: BRFSS, CDC.
Obesity* Trends Among U.S. Adults BRFSS, 1989 (*BMI 30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%-14% 15-19% 20% Source: BRFSS, CDC.
Obesity* Trends Among U.S. Adults BRFSS, 1990 (*BMI 30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%-14% 15-19% 20% Source: BRFSS, CDC.
Obesity* Trends Among U.S. Adults BRFSS, 1991 (*BMI 30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%-14% 15-19% 20%
Obesity* Trends Among U.S. Adults BRFSS, 1992 (*BMI 30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%-14% 15-19% 20% Source: BRFSS, CDC.
Obesity* Trends Among U.S. Adults BRFSS, 1993 (*BMI 30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%-14% 15-19% 20%
Obesity* Trends Among U.S. Adults BRFSS, 1994 (*BMI 30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%-14% 15-19% 20% Source: BRFSS, CDC.
Obesity* Trends Among U.S. Adults BRFSS, 1995 (*BMI 30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%-14% 15-19% 20%
Obesity* Trends Among U.S. Adults BRFSS, 1996 (*BMI 30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%-14% 15-19% 20% Source: BRFSS, CDC.
Obesity* Trends Among U.S. Adults BRFSS, 1997 (*BMI 30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%-14% 15-19% 20% Source: BRFSS, CDC.
Obesity* Trends Among U.S. Adults BRFSS, 1998 (*BMI 30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%-14% 15-19% 20%
Obesity* Trends Among U.S. Adults BRFSS, 1999 (*BMI 30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%-14% 15-19% 20% Source: BRFSS, CDC.
Obesity* Trends Among U.S. Adults BRFSS, 2000 (*BMI 30, or ~ 30 lbs overweight for 5’4” person) Source: Mokdad A H, et al. JAMA 2001;286:10 No Data <10% 10%-14% 15-19% 20%
Obesity* Trends Among U.S. Adults BRFSS, 1991, 1995 and 2000 (*BMI 30, or ~ 30 lbs overweight for 5’4” person) Source: Mokdad A H, et al. JAMA 1999;282:16, 2001;286:10. No Data <10% 10%-14% 15-19% 20%
Clinical Evaluation of Overweight and Obesity--- Assessment Determine severity of patient’s obesity –Overweight and obesity are classified by BMI –Calculated with the formula: –Weight (kg) / height squared (m 2 ) OR –[weight (pounds)/height squared (inches 2 )] * 703
Example For example, if John is 5 foot 10 (1.78 m) and weighs 200 pounds (91 kg), his BMI can be calculated as follows: –BMI = weight (kg) / height squared (m 2 ) = 91 / = 28.7 OR –BMI = [weight (lbs) / height squared (in 2 )] * 703 = 200 / 70 2 * 703 = 28.7
Classifying Obesity by Body Mass Index Classifying obesity by BMI units replaces previous weight-height terminology such as percent ideal or desirable body weight Desirable or healthy weight: BMI = 18.5 to 25 kg/m 2 Overweight: BMI = 25 to 29.9 kg/m 2 Obesity: BMI ≥ 30 kg/m 2
Obesity Trends Among U.S. Adults between 1985 and 2000 Definitions: Obesity: having a very high amount of body fat in relation to lean body mass, or Body Mass Index (BMI) of 30 or higher Body Mass Index (BMI): a measure of an adult’s weight in relation to his or her height, specifically the adult’s weight in kilograms divided by the square of his or her height in meters Definitions: Obesity: having a very high amount of body fat in relation to lean body mass, or Body Mass Index (BMI) of 30 or higher Body Mass Index (BMI): a measure of an adult’s weight in relation to his or her height, specifically the adult’s weight in kilograms divided by the square of his or her height in meters
Obesity Trends Among U.S. Adults Between 1985 and 2000 Source of the data: The data shown in these maps were collected through CDC’s Behavioral Risk Factor Surveillance System (BRFSS). Each year, state health departments use standard procedures to collect data through a series of monthly telephone interviews with U.S. adults Source of the data: The data shown in these maps were collected through CDC’s Behavioral Risk Factor Surveillance System (BRFSS). Each year, state health departments use standard procedures to collect data through a series of monthly telephone interviews with U.S. adults
Clinical Evaluation of Overweight and Obesity Assess patient’s obesity-related risk status –Waist circumference –Distribution of adipose tissue is an important consideration in addition to BMI –Measured by placing a measuring tape in a horizontal plane at the level of the iliac crest without compressing the skin Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. NIH Publication
Weigh Your Patient’s Health Risks Classification of Overweight and Obesity BMI (kg/m 2 ) Obesity Class Disease Risk (Relative to Normal Weight and Waist Circumference ) M ≤ 40 in F ≤ 35 in > 40 in > 35 in Underweight < Normal 18.5 – Overweight 25.0 – 29.9 IncreasedHigh Obesity 30.0 – – 39.9 I II High Very High Extreme Obesity ≥ 40 III Extremely High ---
Metabolic syndrome: Treatment The safest, most effective and preferred way to reduce insulin resistance in overweight and obese people is weight loss and increased physical activity (AHA, 2004) Other steps for managing the metabolic syndrome are also important for patients and their doctors: –Routinely monitor body weight (especially the index for central obesity), blood glucose, lipoproteins and blood pressure. –Treat individual risk factors (hyperlipidemia, hypertension and high blood glucose) according to established guidelines. –Carefully choose anti-hypertensive drugs because different agents have different effects on insulin sensitivity.
Other Co-morbid Conditions Obstructive Sleep Apnea –Often overlooked in obese patients –Symptoms: Very loud snoring Cessation of breathing followed by a loud clearing breath Nighttime awakening Daytime fatigue with episodes of sleepiness at inappropriate times Morning headaches
Other Co-morbid Conditions Obstructive Sleep Apnea Associated findings on examination may include: Hypertension Narrowing of the upper airway Scleral infection Leg edema Lab studies may show polycythemia ( total red cell mass) If signs of sleep apnea are present, diagnostic sleep study should be performed Onset of sleep apnea sometimes associated with further weight gain Management of sleep apnea may assist with weight loss
Medical History History is important for evaluating risk and deciding upon treatment. Questions should address: –Age of onset of obesity –Minimum weight as an adult –Events associated with weight gain –Recent weight loss attempts –Previous weight-loss modalities (successful and unsuccessful) –Complications of the above modalities
Medical History Examples of how a patient’s medical history can affect the outcome of weight treatment –Weight loss to a level at or below the patient’s minimum adult weight occurs very rarely and is difficult to maintain –Treatment modalities that were previously unsuccessful should generally be avoided –History of eating disorders (e.g., anorexia nervosa or bulimia) are relative contraindications to treatment; referral to a specialist is indicated
Medical History (continued) Examples of how a patient’s medical history can affect the outcome of weight treatment –Alcohol and substance abuse require specific treatment which should take precedence over obesity treatment –Cigarette smoking can complicate treatment history because weight is often gained upon quitting; implementing a diet and exercise program upon or before quitting can minimize weight gain
Drug-induced Weight Gain Although most common causes for overweight and obesity are excessive caloric intake and lack of physical activity, medication history should be taken also –Uncover possible drug-induced weight gain –Other medications, which might be interfering with weight loss
Drug-induced Weight Gain –Drugs used to treat the following problems have been shown to cause weight gain or make weight loss more difficult Depression Schizophrenia Mood disorders Seizures Hypertension
Drug-induced Weight Gain The most common weight-inducing drug groups are: Antidepressant medications (tricyclic, SSRI’s) Lithium Antipsychotic medications (phenothiazines, butyropenones, atypical agents) Anti-epileptic agents (valproic acid and carbamazepine) Steroid hormones (corticosteroid derivatives, megestrol acetate, estrogen) Antidiabetic medications (insulin, sulfonylureas, thiozalidinediones)
Endocrinological Causes of Obesity Hypothyroidism Cushing’s syndrome (incidence: 1 per 100,00) Insulinoma (tumors which excrete excessive amounts of insulin) Hypothalamic tumors or damage to this part of the brain Endocrine diseases are rarely the sole cause of obesity
Contraindications to Treatment of Overweight and Obesity Active cancer Any severe illness Pregnancy Eating disorders Medical or psychiatric illnesses must be stable before weight reduction begins Patients with cholelithiasis and osteoporosis should be warned that these conditions might be aggravated by weight loss
Diagnosing obesity in clinical settings BMI as a vital sign Other ways to estimate body fat –Waist circumference: > 40 in. for men, > 35 in. for women predict visceral fat deposition, insulin resistance and metabolic syndrome –Waist-to-hip ratio: >1.0 for men, >.8 for women predicts risk Assessing obesity-related comorbidities Weight gain/loss history
NIH Guidelines for Obesity Treatment Aim for 5-10% sustained weight loss (>1 yr.) for best long-term effect Weight loss maintenance difficult –Longitudinal registries illustrate 10-20% adherence (+/- 10 lbs. of total weight loss) –Tough, but important task! 3500 calorie deficit for 1 lb. weight loss –i.e., 500 calorie deficit per day for 1 lb. weight loss per week
NIH guidelines for obesity treatment, cont’d. Creating an energy deficit –Restrict energy intake: maintain, on average, kcal/day for women, kcal/day for men –Increase energy expenditure: at least 150 minutes of moderate/vigorous physical activity per week, i.e., brisk walking, biking, jogging, swimming –On average, 10 minutes of vigorous activity expends about 100 calories
Treatment Plan –Based on clinical evaluation of patient’s level of obesity and risk factors –Primary Targets for Treatment –Overweight patients with a BMI > 25 plus at least 2 concomitant risk factors –Obese patients with a BMI > 30, regardless of complications
Treatment Modalities Physical Activity Behavioral Therapy Diet Pharmacotherapy Surgery
Goals of Non-surgical Therapies Reduce body weight –Initial weight loss of 10% of body weight over 6 months (recommended target) –Recommended rate of weight loss is 1 – 2 pounds each week –Even modest weight may reduce visceral fat and improve co-morbid conditions Maintain a lower body weight for the long-term Prevention of further weight gain is the minimum goal
Multifaceted Approach Lifestyle approach (dietary therapy, PA, behavioral therapy) Strong evidence supports multifaceted approach –far more effective for wt loss and maintenance than any single approach alone Lifestyle interventions should be attempted for at least 6 months before considering pharmacotherapy
Dietary Therapy Goal –Reduce patients’ daily calorie intake to below maintenance level –Reduction of 500 to 1,000 kcal/day will achieve weight loss of 1 to 2 lbs/week –Women 1,000 to 1,200 calories/day –Men 1,200 to 1,600 calories/day
Portion Control Important factor in patients’ effort to lose and maintain weight –Portion sizes for many foods are much bigger now –Many people misjudge portion sizes 1 bagel = 4-6 slices of bread 1 muffin = 800 calories 16 oz steak = 1625 calories (65% of a person’s wt maintenance calories of 2500) Source: US Dept Agriculture nutrient analysis
National Weight Control Registry National database of > 3000 individuals with average wt loss of 60 lbs maintained for 5 yrs Consumed ~1400 kcal/day (24% fat calories) ~400 calories expended/day in PA (walking is the most frequent PA) 2/3 of successful weight losers were overweight as children and 60% report family history of obesity About 50% lost weight on own without formal program Successful weight losers self-monitor
Popular Diets Typically emphasize one food (and reduce another) Successful for weight loss because they reduce TOTAL calories Higher in protein than RDA (50 gm women, 63 gm men) Studies have shown that 72 gm/day reduces lean tissue in most patients –No evidence that carbohydrates contribute to overweight –Insulin resistance is reduced by weight loss, no matter what diet is used to get wt loss results
Formula Diets 2 kinds of formula diets –Very low calorie diets (VLCD) – 800 calories/day –Meal replacements –Liquid or solid –Can be bought over the counter
Very Low Calorie Diets Must be physician supervised –Usually powder form (mixed with water or milk) –Required vitamins/minerals are contained in 4-5 drinks/day –Produces a rapid and consistent weight loss –Rate of weight loss should be restrained for patients with a history of arrhythmias or MI
Very Low Calorie Diets (VLCDs) VLCDs produce greater initial weight loss than LCDs, which are between 1,000 to 1,500 kcal/day VLCDs promoted weight loss of 13 – 23 kg compared to 9 to 13 kg from LCDs However, at 1 yr long term weight loss is not different from that of LCDs Source: Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. The Evidence Report. NIH Pub #
Pharmacotherapy Useful adjuncts to behavioral therapy Can be considered for those with BMI of 30 – 34.9 kg/m 2 regardless of co-morbid conditions Two FDA approved drugs –Sibutramine –Orlistat
Evidence Report Recommendations Weight loss drugs may only be used as part of a comprehensive weight loss program, including dietary therapy and physical activity –With a BMI of ≥30 with no concomitant obesity-related risk factors or diseases, and –With a BMI of ≥ 27 with concomitant obesity-related risk factors or diseases Weight loss drugs should never be used without concomitant lifestyle modifications. Continual assessment of drug therapy for efficacy and safety is necessary –If the drug is efficacious in helping the patient lose and/or maintain weight loss and there are no serious adverse effects, it can be continued –If not, the drug should be discontinued
Obesity Pharmacotherapy Short term use is not beneficial Without lifestyle modification drugs unlikely to be helpful Few trials lasting 1 year or longer; attrition rates high Net weight loss averages 2-10 kg Most weight loss occurs within 6 months Weight is frequently regained after therapy is stopped Patients expectations ≠ your expectations Evaluate risk/benefit ratio before prescribing –Initial response to therapy appears predictive Better drugs are needed
Long-term Pharmacotherapy Meta-Analysis Weight LossPercent Weight Loss ≥ 10% weight loss Sibutramine N= kg 95%CI: % 95%CI: % 15% 95%CI: 4-27% Orlistat N= kg 95%CI: % 95%CI: % 12% 95%CI: 8-16% Padwal et al. Int J Obesity 2003;27:
Weight Loss Surgery Option for patients with severe or resistant obesity Patients with BMI at least 40 kg/m 2 or less severe (BMI between 35 and 39.9 kg/ m 2 ) if at high risk of comorbid conditions or weight-induced physical problems Must have integrated program that provides guidance regarding diet, PA, and behavior therapy
Obesity Surgical Procedures Two operative approaches –Vertical banded gastroplasty (VBG) –Roux-en-Y gastric bypass (RYGB) Limit storage capacity of stomach to 30 to 50 cm Reduce pouch-emptying rate by creation of a 10mm diameter anastomotic gastrointestinal stoma
Vertical banded gastroplasty (VBG)
Roux-en-Y gastric bypass (RYGB)
Surgical Procedures Average wt loss of approx 50% of excess body weight Maintained in nearly 60% of patients at 5 years For VBG patients, no intestinal absorptive abnormalities For RYGB patients, increased risk for micronutrient deficiencies of vit B12, folate, and calcium –Patients will need to be placed on long-term vitamin-mineral supplements Source: Am Soc Bariatric Surgery
Gastric Bypass Surgery Complications: 14-Year Follow-Up Vitamin B % Readmit for various reasons % Incisional hernia % Depression % Staple line failure9015.0% Gastritis7913.2% Cholecystitis6811.4% Anastomotic problems599.8% Dehydration, malnutrition355.8% Dilated pouch193.2% Source: Pories WJ et al Ann Surg 1995;222:
Summary of Recommendations Clinical Guidelines Measurement of Degree of Overweight and Obesity to Assess Health Risks Goals for Weight Loss How to Achieve Weight Loss Goals for Weight Loss Maintenance
Diabetes Prevention Program (DPP) Reduction of risk of getting type 2 diabetes –Lifestyle intervention 58% –Metformin 31% Subgroup analyses: –Lifestyle intervention worked in all groups, but particularly well in people age 60 and older (71% reduction in dev of diabetes) –Metformin worked especially well among younger (25 to 45 yrs), heavier individuals with BMI of 36 (50 to 80 lbs overweight)
National Weight Control Registry National database of > 3000 individuals who have maintained at least 30 lb weight loss for at least one year –Successful weight losers report making substantial changes in eating and exercise habits to lose weight and maintain their losses. –The average registrant has lost approximately 60 lbs and has maintained that loss for roughly 5 years. –Two-thirds of these successful weight losers were overweight as children and 60% report a family history of obesity. –Approximately 50% of participants lost weight on their own without any type of formal program or help. –Walking is the most frequently cited physical activity performed
Weight Loss Counseling in Primary Care Settings Improvement Needed –Recent BRFSS data of over 12,800 obese adults who were seen by a physician in previous 12 months –Persons who reported receiving advice to lose weight were significantly more likely to report trying to lose weight than those who did not (OR, 2.79; 95% CI, ). –Less than half of obese adults report being advised to lose weight by health care professionals. Galuska et al. Are health care professionals advising obese patients to lose weight? JAMA 1999; 282(16)
Readiness to Change Initiating Weight Control Efforts –Determining readiness and motivation are essential elements of the initial assessment –Most patients know that they have a weight problem, and some will bring up the topic –The way in which the patient is approached can influence the success of efforts to deal with it
Suggestions for Initiating Discussion Determine whether the patient sees the weight status as a problem for anyone but his or her doctor –What do you think about your weight? –Asking such a question sets the stage for addressing the patient’s weight as an issue of mutual concern
Suggestions for Initiating Discussion Focus on the health implications of the patient’s weight –Narrow the discussion to the health consequences –Labels matter. “Obesity” may be a clinical label but some obese patients find it disparaging. Describe the patient’s weight and health status, not the patient –“Your weight is in a very unhealthy range” vs “You are obese”
Focus on Health Risks Associated with Overweight/Obesity K.C. Star 2005
How should you refer to your patient’s weight status Univ of Penn study 2001 Relative desirability of different terms that physicians might use to refer to a patient’s obesity –127 female subjects were asked to imagine that their doctor said to them: “I want to talk with you about your _____” –Had to fill in blank with 11 possible terms –Desirability of each was rated from 1 (most desirable) to 5 (least desirable)
How should you refer to your patient’s weight status? RankTermScore 1Weight2.00 2Body Mass Index2.96 3Excess weight3.08 4Unhealthy body weight3.21 5Weight problem3.21 6Unhealthy BMI3.65 7Heaviness4.00 8Large size4.27 9Obesity Excess fat Fatness4.81 ER Didie et al Obes Res 2001 Most preferred weight (79%)Most preferred weight (79%) Least preferred fatness (74%)Least preferred fatness (74%) 54% selected obesity as one of least preferred 54% selected obesity as one of least preferred
Doctor in Trouble for Calling Patient Obese N.H. woman filed complaint---hurtful not helpful State Attorney General asked to investigate Doctor rejected office’s proposal that he attend a medical education course and acknowledge that he made a mistake. Interviewed on Today’s Show “You need to get on a program, join a group of like-minded people and peel off the weight that is going to kill you.”
Initiate Discussion Step One –Make the most of the patient visit and set an effective tone for communication Patients who are overweight or obese generally have a history of dealing with a frustrating and visible problem Often experience discrimination and hurtful comments However, many patients are comfortable discussing weight with their physician 1 Wadden TA, Anderson DA, Porter GD, et al. Arch Fam Med 2000; 9(9):
3 Steps to Initiate Discussion Step Two –Assess the patient’s motivation/readiness to lose weight –Ask the patient if he/she would consider lifestyle changes to lose weight and improve health –Example: –On a scale of 1 – 10, with 10 being 100% ready to take action, how ready are you to lose weight?
Assessing Readiness to Change If the patient agrees that weight is a problem—seize the moment to assess readiness to make changes –Warning—some patients will verbalize a willingness to change that they do not truly feel –Careful phrasing of questions may help to avoid this –Will you try to lose weight?----demands an affirmative response –Is there anything you think you can do that might help your weight situation?---may open the door to more candid responses
Assessing Readiness to Change Remember –Readiness to change is not an all or nothing matter –Patient may be willing to eliminate sugared beverages but not to begin an exercise program –After establishing the patient’s general patterns of caloric intake and activity, ask which of them the patient is willing to address initially
Tips Establishing rapport with patients –Solicit permission to discuss weight issues –Ask the patient if he/she would be comfortable with discussing general health including weight –Ask about the patient’s weight history and how excess weight has affected his/her life –Express your concerns about the health risks associated with excess weight and how this is affecting the patient –Review the patient’s BMI, waist circumference, and other associated health risks
Tips Establishing rapport with patients (continued) –Use preferred terms such as “weight”, “excess weight,” and “BMI” when describing obesity –Be careful to communicate a nonjudgmental attitude that distinguishes between the weight problem and the patient with the problem
Tips Ask the patient about previous attempts to lose weight. What were the most successful and least successful? Ask about the patient’s physical activity level and attitude toward exercise Ask the patient about the level of support he/she can expect from family and friends Ask about potential barriers to success
3 Steps to Initiate Discussion (continued) Step Three Build a partnership with the patient –Set goals for behavior change together with the patient –Recent study showed that most overweight patients would like assistance with weight management (e.g., dietary and physical activity advice) and setting realistic goals* *Potter WB, Vu JD, Croughan-Minihane M. J Fam Pract 2001; 50(6):
Tips Ask what the patient’s weight goals are Explain that even a small weight loss of 5 – 10 % of initial weight can lower health risks Select 2 or 3 measurable, achievable goals and discuss steps needed to achieve them Provide and discuss patient handouts and/or refer patient to dietitian or exercise specialist
Summary Step One –Make the most of the patient visit and set an effective tone for communication Step Two –Assess the patient’s motivation/readiness to lose weight Step Three –Build a partnership with the patient by setting goals for behavior change together
Review Case Studies
Do You Know How Food Portions Have Changed in 20 Years? National Heart, Lung, and Blood Institute Obesity Education Initiative
BAGEL 20 Years Ago Today 140 calories 3-inch diameter How many calories are in this bagel?
140 calories 3-inch diameter Calorie Difference: 210 calories 350 calories 6-inch diameter BAGEL 20 Years Ago Today
How long will you have to rake leaves in order to burn the extra 210 calories?* *Based on 130-pound person Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out
If you rake the leaves for 50 minutes you will burn the extra 210 calories.* *Based on 130-pound person Calories In = Calories Out
CHEESEBURGER 20 Years Ago Today 333 caloriesHow many calories are in today’s cheeseburger?
Calorie Difference: 257 calories 590 calories CHEESEBURGER 20 Years Ago Today 333 calories
Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out How long will you have to lift weights in order to burn the extra 257 calories?* *Based on 130-pound person
If you lift weights for 1 hour and 30 minutes, you will burn approximately 257 calories.* *Based on 130-pound person Calories In = Calories Out
SPAGHETTI AND MEATBALLS 20 Years AgoToday 500 calories 1 cup spaghetti with sauce and 3 small meatballs How many calories do you think are in today's portion of spaghetti and meatballs?
Calorie Difference: 525 calories 1,025 calories 2 cups of pasta with sauce and 3 large meatballs 20 Years AgoToday 500 calories 1 cup spaghetti with sauce and 3 small meatballs SPAGHETTI AND MEATBALLS
How long will you have to houseclean in order to burn the extra 525 calories?* *Based on 130-pound person Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out
*Based on 130-pound person If you houseclean for 2 hours and 35 minutes, you will burn approximately 525 calories.* Calories In = Calories Out
FRENCH FRIES 20 Years AgoToday 210 Calories 2.4 ounces How many calories are in today’s portion of fries?
610 Calories 6.9 ounces Calorie Difference: 400 Calories FRENCH FRIES 20 Years AgoToday 210 Calories 2.4 ounces
How long will you have to walk leisurely in order to burn those extra 400 calories?* *Based on 160-pound person Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out
*Based on 160-pound person If you walk leisurely for 1 hour and 10 minutes you will burn approximately 400 calories.* Calories In = Calories Out
85 Calories 6.5 ounces How many calories are in today’s portion? SODA 20 Years AgoToday
Calorie Difference: 165 Calories 250 Calories 20 ounces 85 Calories 6.5 ounces SODA 20 Years AgoToday
How long will you have to work in the garden to burn those extra calories?* *Based on 160-pound person Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out
If you work in the garden for 35 minutes, you will burn approximately 165 calories.* *Based on 160-pound person Calories In = Calories Out
320 caloriesHow many calories are in today’s turkey sandwich? TURKEY SANDWICH 20 Years AgoToday