1. Baseline

2. Caloric Balance Caloric Intake + Expenditure = +/- Caloric Balance

3. Case 1 50 year old woman, in good health, no history of cigarettes, in for check up. BMI 29. Should you tell her she is overweight? What further assessment and treatment should you begin?

4. An Office-Based Approach  Make the diagnosis (and communicate it)  Assess readiness for change  Prescribe diet and exercise  Consider medications and surgery

5. HEALTH PROFESSIONAL ADVICE AND WEIGHT LOSS 12,835 adults, BMI over 30 kg/m 2, check-up in last year Random-digit, population-based sample, 50 states 42% told by health professional to lose weight  Those told to lose weight more likely to report trying to lose weight: OR 2.79 (95% CI 2.53- 3.08)

6. Gregg, Ann Int Med 2003 INTENTIONAL WEIGHT LOSS AND DEATH Prospective CDC cohort study, 6391 adults, followed for 9 years Those reporting intentional weight loss had 24% reduction in mortality Those reporting unintentional weight loss had 31% higher mortality Those reporting attempted but unsuccessful weight loss also had 20% reduction in mortality

7. GOALS OF MANAGEMENT Be as fit as possible at current weight Be as fit as possible at current weight Prevent further weight gain Prevent further weight gain If successful at 1 and 2, begin weight loss If successful at 1 and 2, begin weight loss

8. Case 2 50 year old woman, in good health, in for check up. BMI 32 with metabolic syndrome. She says, “ I have to lose weight, and I am planning on doing that. I am about to try the South Beach diet.”

9. Anderson, Am J Clin Nutr, 2001 VLCD’s vs LCD’s: Meta-analysis of 29 U.S. Studies Weight loss studies with > two year f/u 13 VLCDs, 14 LCDs Mostly observational studies (few RCT’s) Weight loss (as % of initial weight): 1y2y3y4y5y LCDs7.24.23.52.82.0 VLCDs 16.19.7 7.87.06.2

10. Dansinger, JAMA 2005 COMPARISON OF ATKINS, ORNISH, WEIGHT WATCHERS, AND ZONE Atkins Ornish WWZone Atkins Ornish WWZone Wt Loss (kg) 2.1 3.33.0 3.2 Completers (%) 53 5065 65 Completers at 1 year Atkins Ornish WWZone Atkins Ornish WWZone Wt Loss (kg) 3.9 6.64.6 4.9 160 patients, randomly assigned

11. Wei, JAMA 1999 FITNESS AND MORTALITY Aerobics Center Longitudinal Study CV death (RR) normal overweight obese normal overweight obese Fit1.01.51.6 Not fit3.14.55.0 Total death (RR) normal overweight obese normal overweight obese Fit1.01.11.1 Not fit2.22.53.1 25,714 men, 44 years old, 14 year observational study

12. Wing and Hill, Ann Rev Nutr, 2001 SUCCESSFUL WEIGHT LOSS MAINTENANCE <3000 subjects in National Weight Control Registry: 30-lb weight loss for 1-year <Average weight loss 30kg (10 BMI units less), average weight maintenance 5.5 years <45 years old, 80% women, 97% Caucasian <46% overweight as child, 46% one parent obese, 27% both parents

13. Wing and Hill, Ann Rev Nutr, 2001 SUCCESSFUL WEIGHT LOSS MAINTENANCE High levels of physical activity Women 2545 kcal/week, men 3293 kcal/week Women 2545 kcal/week, men 3293 kcal/week (1-hour moderate intensity per day (1-hour moderate intensity per day Only 9% report no physical activity Only 9% report no physical activity Diet low in fat, high in carbohydrate 1381 kcal day, 24% fat, 19% protein, 56% CHO 1381 kcal day, 24% fat, 19% protein, 56% CHO 4.87 meals or snacks/day 4.87 meals or snacks/day Fast food 0.74/week Fast food 0.74/week Regular self-monitoring of weight 44% weigh once per day; 31% once per week 44% weigh once per day; 31% once per week

14. Issues History: Modified PA Questionnaire & Weight Gain Patient handout. Baseline Data Plan