1. Hélène Charlebois, RD HC Nutrition Inc. Consulting & Wellness Weight Management Specialist Certified in Adult Weight Management Level 1 & 2 Academy of Nutrition & Dietetics (ADA) Waisting Away TM 2012 Empowering “FUTURE” Health Professionals with Weight Management Knowledge / Research / Practice for Health at ANY Size!

2. Research - Information Academy of Nutrition & Dietetics AND Weight Management Training level 1 & 2 + new certification ADA Weight Management DIPG Canadian Obesity Guidelines CON – Canadian Obesity Network Summit – attend & present on line newsletter, research DC Obesity Learning Retreat Blogs by Dr Arya Sharma and Yoni Freedhoff Dr. Sharma's Obesity Notes » blog [amsharm@ualberta.ca] Weighty Matters [yonifreedhoff@gmail.com] New - points towards IASO’s Specialist Certification for Obesity Professional Education (SCOPE). www.hcnutrition.com

3. Ask for permission to discuss weight and explore readiness for change Assess obesity elated health risk and potential “root causes” of weight gain Advise on obesity risks, discuss benefits treatment options Agree on realistic weight-loss expectations and on a SMART plan to achieve behavioral goals Assist in addressing drivers and barriers, offer education and resources, refer to provider, and arrange follow-up The 5 A’s of Obesity Management is a set of practical tools to guide primary care practitioners in obesity counseling and management:

4. What are DIETS? Billions and billions of $$$ All diets work Recent research – 75 years of dieting Most weight loss is in the 1 st 6 months Skills

5. Treating Patients What Docs say? Recommend to lose 21% of their weight UNREALISTIC ! Treat distress not depression On line – 80% want an in home diet plan Apps – in 2010 = $910 million Getting the church involved But… obesity cost was 4.6 Billion in 2008 (usa) and increase of 20% from 2000

6. Weigh 1x/week; do something about weight gain Planned and structured; eat similar foods Low calories/fat; 1800 cals + 30% fat Eat breakfast Eat out less than 3 x/wk; fried foods less than 1x/wk Active1 hour per day – simply move more! Less than 10 hours per week of “screen watching”

7. Measuring Obesity Waist Men = 102 cm ; women = 88 cm High risk: men = 90 cm ; women = 80cm South Asian & Aboriginal = High Risk Hip Waist to hip Anthropometric BIA – In Body – BOD POD- DEXA How to measure???

8. Bariatric Surgery Restriction of food Less eating – size of a golf ball Less food How to deal with comfort eating Malabsorptive Malnourishment – pre and post Macro / micronutrients Neural & Hormonal Pathways

9. Bariatric Surgical Options 30 to 80% loss EBW Expanding in Canada Surgery - 5 different procedures Adjustable Gastric Banding Roux en Y gastric bypass – less 50% EBW/ 1 st yr Biliopancreatic Diversion/duodenal switch Sleeve Gastrectomy Gastric Ballooning / Endo Barrier What about Fatty Liver Disease? Correcting for Vitamin D deficiency

10. Bypass- 80% ebw 2 Multivitamin mineral for life Iron, folic acid and B12 (1200 mmg) Take Vitamin C 500 mg with Iron 300 mg 1 to 3/day Calcium 1200-2000 mg elemental calcium Liquid or tabs – Citrate is best No take more than 500 mg at a time Take even if 2-4 servings of dairy per day Vitamin D – make sure in Calcium Supp. At least 1000 IU/day Protein = calculate needs 0.8-1.0 g per kg; 0.91 g/kg actual body weight; 1.5-2.1 g/kg ideal body weight B12 over time – doc to assess 500 mcg sublingual

11. Why the Weight Loss in Surgical Patients? At 1 month = decrease in gut hormones then stable GLP1, incretins, GIP, Amylin, Glucagon, Proinsulin, C peptide At months 2 to 12 = decrease FBS, insulin, decrease in food and absorption Stomach + intestines = largest endocrine system ‘CURE’ for diabetes?

12. Staging System – Dr.A Sharma Need for a better diagnostic system 0 – obese but not risk factors 1 – subclinical factors, mild symptoms 2 – chronic disease, mobility limitations 3 – end organ damage- significant limits Impairment of well being 4 – severe disabilities

13. Hormones affecting weight Hunger stimulus Hedonic Homeostatic Appetite Do food addictions exist?

14. Cortisol - brain Fight or flight hormone Sleep deprived Screen watching Makes you hungry Increases belly fat Sleep patterns Sleep before midnight- most sleep before 530 am No eating after 8pm

15. + Sleep Deprived Less sleep Increase hedonic stimuli = Increase food consumption Decrease leptin Increase ghrelin & cortisol Trying to reach glucose homeostasis Kids - teens

16. Insulin - pancreas Stores body fat High insulin levels = burns carbohydrates Low insulin levels = burns fat Therefore, we will burn more fat if eat less carbs

17. Dopamine – brain = Opioid syndrome The “chocolate” hormone Hypothesis Cravings- sweet tooth Similar to endorphins Obese = decreased receptors = decreased bliss point

18. Serotonin Brain Decrease in winter Feel good hormone Estrogen link Low serotonin Decreased hunger Increased anger SSRIs

19. Ghrelin – gut – hunger hormone Controls weight Controls glucose homeostasis Hunger and appetite The ONLY hunger hormone

20. Leptin- protein-hypothalmus Appetite suppressant Controls appetite Energy in Energy out gene Produced by fat tissue Obese has high leptin but it is resistant NEEDED: a system that will “sensitize” Dopamine Link?

21. Incretin- GLP1 – intestine Increase insulin secretion Decrease appetite Decrease glucagon Decrease sugar production by the liver Gets insulin ready New diabetes medication = Victoza,Byetta

22. % Weight Loss Diet & Exercise- Lifestyle 3 - 5 - 10 % Pharmacotherapy 5 – 10 - 15 % Bariatrics 20 - 30- +++ % up to 80% EBW

23. + Food - the nutrient link is broken Food & Ingredients Increase quantity of high quality foods Decrease quantity of low quality foods Ready to EAT Less protein, fibre, vits, mins More sugar, fat salt More energy Food and in

24. + Making Changes – are they ready? For what? Healthier living Healthier being Disease prevention Disease state management They came to you… level of readiness Ask the question Easy to lose weight but not easy to keep the weight off Must be ready to make lifestyle lifetime changes More in Behavior section WHY? HOW?

25. + Clean up your House House needs to be a ”Positive Health Environment” Set up for SUCCESS Food availability is too high Make it healthy Get rid of your trigger foods – unsafe foods DANGER FOODS Look into kitchen cupboards, fridge, pantry Purge “unhealthy” foods Office; desk drawer Replace with healthier food options WHY? HOW?

26. + Successful Set Up Must keep great tasting healthy foods around you At all times Increases your rate of success Studies show… “out of sight out of mind” Fruit & Veggie shopping Bagged, trays, frozen, fresh, canned…it all counts Keep some everywhere Lean meats Desk drawer Legumes- new recipes WHY?HOW?

27. + Choose only whole / sprouted grains Why? Change the box! Eating whole grain, sprouted, high fiber foods Keep you fuller, longer Low GI Are healthier for you Refined processed starches digest quickly How? Stick to whole grain, whole wheat product Pasta, brown rice, crackers, cereal No white rice-why? Try different grains Sprouted grains

28. + No bagels??? No bananas No white potatoes Why? Change the box! Bagels- +300 calories Available: low GI / 150 calories Bananas and potatoes are favorites so take them out… make a change… you’ll be amazed! How? Choose whole grain breads/ english muffins Have any other fruit and any other vegetable.. Try to think outside the box… variety is key

29. + Eat low GI Foods Keeps you fuller, longer Generally higher fiber and healthier foods Control blood sugars Control cholesterol level Gives some boundaries Take with a “grain of salt ” www.glycemicindex.com www.diabetes.ca Eat lots of whole fruits and vegetables Eat whole grains Eat lean meats and low fat dairy products Add fiber to foods Why?How?

30. + Meal Balancing Nutritionally adequate All nutrients More even distribution of starch and protein See chart and guidelines HEP sheet Protein at all meals More even distribution of starch to protein Up to 25% protein Have protein with PM snack WHY?HOW?

31. + No Starch at Supper Reducing the total calorie intake Less cals at supper and beyond is key Starch at supper = Lots of calories We LOVE starch Insulin and belly fat HS more sedentary Replace your starches with vegetables Use spaghetti squash Use a bed of corn instead of rice Use bean sprouts instead of pasta Sweet potato/yams are great Ok for starchy vegetables Legumes are great ! WHY?HOW?

32. + Journaling Awareness Understanding Patterns Accountability But… most HATE journaling! See the CFC sheet Same as the “meal balancing” Journaling sheet Create own Journaling book / on line www.myfitnesspal.com APPS : The Future! WHY? HOW?

33. Journaling continued Make journaling effective Pick your battles Be realistic Be flexible Different journaling strategies Only HS intake Only activity Only after lunch and beyond

34. + Plan your Snacking Small snack = eat less at meal times Do not “rip the fridge door off” Up to 40% total daily calories Too often Too much-portions Too calorie dense The 4 th Meal! Plan a small snack 1 hour before meals AM= 80 calories Yogurt, fruit PM = 100 -150 calories This is the important one Protein + fruit/veg HS = 100 -150 calories Sweet/salty tooth WHY?HOW?

35. + Calorie Distribution Calories count Recent research; all diets work in the short term More even distribution throughout the day See chart and guidelines HEP sheet WHY?HOW?

36. Meal Balancing Protein Fruit Starch Protein Starch 2 Vegetables Fruit Protein + fruit 100-150 calories Protein Starch 2 Vegetables Meal balancing = It is important to have a protein at each meal; starches should be whole grains. BREAKFAST= 300cals LUNCH= 400-500cals DINNER= 400-500cals snack snack snack HINT: For added weight loss, no starch at supper but load up on the veggies!

37. Calorie Distribution/Protein Breakfast = Starch 150 cals/20g am snack = 80 calories/10g Lunch=St.150 cals; prot.150 cals/20g pm snack = 100 to 150 calories/10g Supper = St. 0 cals to 300 cals/20g hs snack = 100 (150) calories

38. + PROTEIN- U of Texas 20 to 30 grams at breakfast 20 to 30 grams at lunch 20 to 30 grams at supper NO MORE NO LESS! WHERE THE MEAT!

39. + Reintroduce Starch at Supper Because we like it! There are special occasions There are exceptions to every rule BUT…. No more than 2 times per week 1 cup = 300 calories Do not have the starch at lunch OR ½ cup at supper nightly Must be measured Reduce protein WHY?HOW?

40. + Portion Distortion Supersizing More for less Restaurant portions The food container is simply too much Our eyes are bigger than our stomachs Bottom line We just eat too much! Label reading Be visual Change the plate Show portions of food Food models? calories Measure it out We are not good at eye balling Load up on veggies 2-3 fruit per day WHY?HOW?

41. + Vegetable 1 st on Plate Our eyes are bigger than our stomachs We always put more of the first item on our plates Research Xmas Put vegetables 1 st on the plate Then the protein Lastly is starch WHY? HOW?

42. + Set up Buffet How you set up the plates How you set up your counter for plate preparation It makes a difference Always put veg 1 st Then protein Last starch Try this at home… you will be AMAZED! WHY?HOW?

43. + Eat close to farm This is my motto Very simple concept Farm foods are usually: Lower in calories Higher in fiber Bountiful More filling Keeps you fuller longer More nutritious Eat whole foods If the food comes from the farm, eat it… if the food leaves the farm, judge it. Give some examples apple vs apple sauce vs apple juice WHY? HOW?

44. + Damage control We all “cheat” but our patients feel guilty about it Feel good about it Plan it Move on 2 types of damage Planned = sandwich it in Unplanned = 48 to 72 hours revenge Don’t get angry get even! WHY?HOW?

45. + Eating Out Because it is part of life RUIN IT! Many handouts available ‘Heart & Stroke Ontario’ www.myfitnesspal.com See internet Plan choices on line Do not take menu Take away the guilt Trading off choices Move away from the bread Order 1 item at a time TRAVELLING? WHY? HOW?

46. + Beverages Count Hidden calories You would not believe Portion distortion Single serving sizes are just too big New journal Snack & Beverages Labels for portion sizes Show glasses, cups Journal beverage intake for one week Count calories on beverage intake Clear on Calories Initiative Diet pop? WHY?HOW?

47. Why? Quick & Easy Controlled eating – no thinking Eliminate complex food choices Eliminate complex meal planning Meal Replacements (cont’d) Waisting Away TM Weight Management Strategies

48. What about Protein Shakes? Stomach = volume detector Intestine = nutrient detector Saliva = brain –nutrient detector Chewing & Tasting

49. Exercise / Activity STRUCTURED UNSTRUCTURED Anti-Sedentary Movement % effect on weight loss? Weight is Food; Health is FOOD & FITNESS

50. What does it do? Burns the visceral fat Keeps the heart muscle strong Is fun! How to do it Walk, run, bike Group sports Soccer, hockey Family Fun Skating, skiing, tobogganing, biking Cardio

51. Preserves lean body mass Sense of accomplishment Great to keep your muscles as you age Osteoporosis prevention Sit ups – push ups Pilates – yoga Weights Exercise ball Bands Gym machines Use your body Lunges Strength Training What does it do?How to do it

52. Flexibility Stretching Mobility Motion Increased quality of life (QOL) HOW? Morning stretches Yoga

53. How much EXERCISE? Health Improvement = 150 minutes / week Weight Loss = 150 to 250 minutes / week Significant Weight Loss = + 250 minutes/wk Weight Gain Prevention (after wt loss) + 250 minutes / week Is this unrealistic? N E A T phenomenon

54. + Walk at Lunch time Only time for one’s self Get out of work Peace of mind Change of scenery All around health Mind Body Soul Eat ½ lunch Go for a walk Eat the other ½ lunch Bring runners to work Bag lunch = more time to walk Buy lunch = must get out and go for a walk but… www.tractivityonline.com WHY?HOW?

55. What about your Metabolic Rate? “You HAVE to eat LESS BUT You WANT to eat MORE!” We are not balanced! Lose 1% / year

56. Pharmacotherapy Xenical – orlistat Meridia – Sibutramine- off market Approval ?? = Qnexa, Lorcaserin, Belvic High Fibre Products Why use? Needed for the disease of Obesity???

57.  Metamucil  PGX Expands in stomach Keeps you fuller longer Less 28 kcals/day= 1.7 kg per year wt loss Great for between meal hunger  Or take before a meal to eat less Mix in juice, yogurt, applesauce, pudding Mix with water; drink 15 minutes before your meal. Non-Prescription Medication High Fibre Products HOW? WHAT? Waisting Away TM Weight Management Strategies

58. + PGX Powder or capsules Keeps you fuller longer Has 3 different types of fiber Konjac-mannan ( root) Sodium alginate Xanthan gum No dairy, corn, soy, starch, wheat, yeast www.pgx.com. www.pgx.com Great as a snack PM or HS Mix in with yogurt, applesauce, pudding Do not let it sit too long Individual sticks for the office; large can for the home Veronica Kacinik [vkacinik@functionalmedicine. ca] WHY? HOW?

59. Other wt loss pills & potions RASPBERRY KETONES – Slendesta Pure green coffee extract African Mango Herbal products – orange peel? Chocolate – Acai –Chocolate with soluble fibres Ephedra USA commercials Product availability BANDAID SOLUTIONS!

60. Weight Maintenance- Summarized WE must prevent HUNGER Low fat calorie conscious eating Planned structured eating Eat breakfast daily Monitor your weight High daily levels of activity Less screen watching Simply move more!

61. Maternal Weight Gain – not anymore! Overweight = 3x increase wt of baby ; obese = 7x CON – U of O BMI over 40 = safe to decrease 5 kg 4.1 kg weight loss is optimal

62. Who is to blame? The environment? You? Reality – Obesity is a complex issue. It requires a collaborative approach, with health professionals, gov’t and industry. Education is key! The ‘NO’ Factor

63. Study 84 hour period of TV watching Keeping track of the foods that are advertised Compared to the Daily Values 2560% over for sugar 2080% over for fat 40% less for vegetable consumption 32% less for dairy consumption 27% less for fruit consumption

64. Neighborhood FOOD DESERTS More fast food choices = more sick and disease = obese neighborhoods Access to unhealthy food choices Price SOLUTIONS? Calories on Menus? Calorie Literacy?

65. - Not aware of 90% of our food choices - 62% too busy to sit down to eat Think Nourish Live Adjust Awareness Journal - observations Society on the Go! Feel – Think – Enjoy Nourish – Smell – Taste

66. + Joint Decision Making Roll with the punches No resistance Empathy Self efficacy Personal goals It’s all about them YOUYOUR CLIENT

67. Call to Action – stop, continue, start Waisting Away TM Manual – NEW! Www.lowgimeals.com http://www.1shoppingcart.com/app/?af=1488220 Nancy Guppy’s menus dietitian@chapmanslanding.com Go to www.chicken.ca Nutrition Fact Sheetswww.chicken.ca # 6 on Tracking Weight Loss General Health, Women’s Health, Diabetes, Heart, Sodium, Screen Watching, Healthy Snacks Food Journals – Snack & Beverage Journals

68. Websites www.hcnutrition.com www.obesitynetwork.ca www.myfitnesspal.com www.calorieking.com www.nutritiondata.com www.sparkpeople.com www.fitday.com www.glycemicindex.com www.myFoodDiary.com www.dietsinreview.com www.eatrightontario.org talk to an RD – snack list www.eatrightontario.org www.dietitians.ca meal planners, eat tracker www.dietitians.ca