Obesity

http://www.ketonutrition.org/# < video Blogs

Fasting Mimicking Diet

Fasting Mimicking Diet

Fizz lecture – sugar metabolism and Warburg effect

Lectures, Interviews, Podcasts, Articles
TEDx Tampa Bay
Tim Ferriss Podcast #1 (Cancer, Fasting, Lifestyle, etc)

Tim Ferriss Podcast #2 (Ketogenic Diet Questions)
Tim Ferriss Podcast #3 (Disease Prevention, Ketone Esters)
Quantified Body Podcast (Leveraging Ketones)

Smart Drug Smarts (Exogenous Ketones, Ketone Esters)

Podcast with Vinnie Tororich 

Podcast with NourishBalanceThrive

 
Publications on Academia.com
Profile and Publications on LinkedInBlogs:
Tim Ferriss: Toolkit for Defeating Cancer
The Eating Academy (Peter Attia)
KetoNutrition Blog
Dr. Jay’s Blog
Ramblings of a Carnivour
Robb Wolf’s Blog and Cancer Article
THINCS (Cholesterol Skeptics)
Guide to Ketosis
The Ketogenic Diet for Health (lots of information here)
Jimmy Moore’s Blog: (Nutritional Ketosis information)
Chris Beat Cancer Website and Blog
Dr. Mary Newport’s website  (Alzheimer’s disease)
Mark’s Daily Apple:  (Paleo information)
Dr. Georgia Ede’s excellent article Diagnosis Diet

Video News
Starving Cancer: Ketogenic Diet as a Key to Recovery
Sugar and Cancer (Lorie Johnson; CBN News)
Coconut Oil and Alzheimer’s Disease (Dr. Mary Newport)
Deanna Protocol for ALS (Winning the Fight)Videos
Metabolic Management of Cancer (Dr. Thomas Seyfried)
Insulin Inhibition as Cancer Therapy (Dr. Eugene Fine)
Paleo Diet for Treatment and Prevention of Cancer (Dr. Klement)
Glucose Deprivation for Cancer Therapy
Carbs and Cholesterol (Dr. David Diamond)
Good Calories Bad Calories (Gary Taubes)
The Obesity-Cancer Connection Panel (with Jeff Volek and Gary Taubes)
Ketone Esters and Neuroprotection (time 5:12 on video)News and Magazine Articles
Scientific America article on Ketogenic Diet
Brain Cancer and Chemo
Boston College News (supporting evidence)
Ketones and Longevity

Press Announcements _ FDA approves AspireAssist obesity device

Bariatric Surgery Types

http://www.clevelandclinicmeded.com/online/webcast/

The protein-sparing modified fast for obese patients with type 2 diabetes: What to expect

http://www.suppversity.com/ LECTURES

FASTING, LONGEVITY, and CANCER 2013 lecture

 

http://www.upmcphysicianresources.com/cme-course/augmenting-cancer-therapy-through-diet

https://www.buchinger-wilhelmi.com/ < Therapeutic fasting clinics

http://www.healthpromoting.com/

http://fasten.tv/en/vortraege/boschmann

KetoNutrition

Foods
http://www.questketo.com/http://www.getbutcherbox.com/#_a_donationUSFfoundationResearch Papers (Free Downloads): https://usf.academia.edu/DominicDAgostino/Papers

Support student research at USF (501c3;nonprofit):
https://usffdn.usf.edu/apps/?fund=250244&a=FUND

Keto Consulting, Doctors, HBOT Resources, Books and Podcasts

 

 

 

Bariatric Surgery Procedures

Lap Band

Long-term Follow-up After Bariatric Surgery

Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric

From bariatric to metabolic surgery Looking for a disease modifier surgery for type 2 diabetes.

Fifteen-Year Follow-Up of Adjustable Gastric Banding and a Systematic Review of the Bariatric

Prevalence of alcohol use disorders before and after bariatric surgery

Substance Use after Bariatric Surgery A Review

Biliopancreatic Diversion The Effectiveness of Duodenal Switch and Its Limitations

Vagal stimulator

Long-term multiple intragastric balloon treatment–a new strategy to treat morbid obese patients refusing surgery prospective 6-year follow-up study

Aspire weight loss device

Intragastric Balloon for Overweight Patients.

http://www.thinnertimes.com/weight-loss-surgery/gastric-bypass/gastric-bypass-outcomes/all-pages.html

Interdisciplinary European Guidelines on metabolic and bariatric surgery

Nutritional Deficiencies in Obesity and After Bariatric Surgery

Protein Ingestion before Sleep Increases Muscle Mass and Strength Gains during Prolonged Resistance-Type Exercise Training in Healthy Young Men

Medical management of patients after bariatric surgery Principles and guidelines

Noncompliance with Behavioral Recommendations Following Bariatric Surgery

Diet after gastric bypass

Artificial sweeteners produce the counterintuitive effect of inducing metabolic derangements.

Non-nutritive sweeteners review and update.

Gain weight by going diet Artificial sweeteners and the neurobiology of sugar cravings

Diet Soda Intake Is Associated with Long-Term Increases in Waist Circumference in a Biethnic Cohort of Older Adults The San Antonio Longitudinal Study of Aging

Non-Nutritive and High Intensity Sweeteners
  • Sucralose (Splenda®)
    • 600 x sweetness of table sugar
    • Heat stable
  • Saccharin (Sweet ‘N Low®, Sweet Twin®, Sweet’N Low®, and Necta Sweet®)
    • 200 to 700 x sweetness of table sugar
    • Used in cooking or table use
    • Effect of bladder cancer in rats was not found in humans. FDA (2015) has deemed saccharin “safe for human consumption.”
  • Acesulfame potassium (Ace-K) (Sunett®, Sweet One®)
    • 200 x sweetness of table sugar
    • Heat stable
  • Neotame (Newtame®)
    • 7,000 to 13,000 x sweetness of table sugar
    • Heat stable
  • Advantame
    • 20,000 x sweetness of table sugar
    • Heat stable
  • Steviol glycosides rebaudioside A and D, stevioside (Rebiana, Truvia®, PureVia®)
    • 200 to 400 x sweetness of table sugar
    • FDA has received “generally recognized as safe” (GRAS) notices for many high purity glycosides and has not questioned the notifiers determinations.
  • Luo Han Guo fruit extracts (Siraitia grosvenorii Swingle fruit extract – SGFE)
    • 100 to 250 x sweetness of table sugar
    • Contain mogrosides
    • GRAS notices received by FDA and not questioned

(AND, 2012; FDA, 2012 & 2015)

Nutritive Sweeteners

Only one high-intensity sweetener is permitted for use in the U.S:

  • Aspartame (Nutrasweet®, Equal®, and Sugar Twin®)
    • 100 to 250 x sweetness of table sugar
    • Is not associated with adverse effects in the general population; however, individuals may have adverse reactions.
    • Does not affect appetite or food intake.
    • Does contain a few calories
    • Contraindicated for individuals with PKU
    • Not heat stable

(AND, 2012; FDA, 2012 & 2015)

Position of the Academy of Nutrition and Dietetics for nutritive and non nutritive sweeteners

Sugar alcohols are low-calorie alternatives to sucrose that increase blood sugar less than sucrose. They are increasingly found in processed foods. They are prepared from sugars, are less sweet, and have fewer calories than sucrose. They are sometimes used as a sugar substitute for weight loss (ADA, 2014). Foods containing sugar alcohols are often labeled “no sugar added” or “sugar-free.”

Common sugar alcohols include:

  • Xylitol
  • Sorbitol
  • Lactitol
  • Mannitol
  • Maltitol
  • Arebitol
    • Erythritol

(ADA, 2014)

Risks/Benefits of Sugar Alcohols

A review of the literature by the Academy of Nutrition and Dietetics concluded that sugar alcohols:

  • Can cause GI side effects (bloating, diarrhea & flatulence), but tolerance may develop with continued use.
  • Are incompletely absorbed and can cause symptomatic bloating in high quantities.
  • May be useful for carbohydrate management by diabetics and people on low-carbohydrate diets.
  • Have limited evidence on their metabolic effects.

Sugar Alcohols

 

Caffeine increases sugar-sweetened beverage consumption in a free-living population

Caffeine toxicity in forensic practice

Effects of carbohydrates on satiety

Evidence suggests that portion size reductions during breakfast lead to reductions in gastrointestinal hormone secretion. Study participants report lower levels of fullness, increased hunger, and increased desire to eat following a 40% reduction of their breakfast portion

Effect of reducing portion size at a compulsory meal on later energy intake, gut hormones, and appetite in overweight adults

Acute Exercise and Hormones Related to Appetite Regulation

he following tips can help patients decrease portion sizes at home.

  • Decrease plate size. Many people keep eating until the food on their plate is gone and then stop. Starting with less, they eat less.
  • Pre-portion snacks. With bigger packages, people often continue eating past the recommended portion. Dividing the large package into portion-sized containers as soon as it is purchased circumvents this.
  • Keep snacks out of sight. Keeping these items out of sight may reduce exposure to cues that activate pleasure seeking pathways in the brain.
  • As with other changes made to diet to reduce total caloric intake, it is important to explain to the patient that these changes in portion size will likely need to be made life-long rather than temporarily. Lasing weight loss comes from lifestyle change rather than from temporary change or “dieting.”

Exercise-Trained Men and Women Role of Exercise and Diet on Appetite and Energy Intake

http://health.gov/dietaryguidelines/2015/guidelines/appendix-3/

Post-Exercise Recovery Fundamental and Interventional Physiology

Cardiac Parasympathetic Reactivation Following Exercise

INTERACTIVE DIET CALCULATOR

What To Eat

ChooseMyPlate.com

  • Vegatables and fruits should fill around half of a plate (at least 5-9 servings per day: 5 vegetables and 2 or fewer fruits is ideal), with an emphasis on:
    • dark-green, red, and orange vegetables
    • beans and peas (legumes and therefore also part of the protein group)
  • Eat whole grains and reduce foods with added sugars. Note that many patients interpret “whole grains” to include processed foods that include some whole grains but are sugar-sweetened, such as many processed breakfast cereals. Also, in a weight-loss diet, it would be best to avoid all added sugars.
  • Eat a variety of low-fat proteins:
    • seafood (at least two servings of fish per week)
    • lean meat
    • legumes
    • soy products
    • nuts and seeds
  • Cut all* synthetic trans fats and partially hydrogenated fats. Use oils to replace solid fats. Although this recommendation in MyPlate actually said to “reduce” synthetic and partially hydrogenated fats, current recommendations are to completely avoid synthetic trans fats (FDA, 2015).
  • Limit sodium intake.

mYpLATE

Chronobiological aspects of food intake and metabolism and their relevance on energy balance and weight regulation

Intermittent Fasting and Human Metabolic Health.

Potential role of meal frequency as a strategy for weight loss and health in overweight or obese adults

Eating Frequency, Food Intake, and Weight A Systematic Review of Human and Animal Experimental Studies.

Meal timing affects glucose tolerance, substrate oxidation and circadian-related variables

  • Frequency: The American Dietetic Association (2009) states that the daily distribution of calories should be consumed with four to five meals and snacks. However, in several studies, this approach failed to aid in weight loss or prevent weight gain (Kulovitz et al., 2014; Leidy, 2011).
  • Morning Meals: Eating breakfast every day may affect weight management by reducing appetite (AHA, 2014; Kulovitz et al., 2014). Taking in small morning meals split over time may help control appetite better (Ekmekcioglu & Youitou, 2010).
  • Delayed Meals: Eating later in the day may contribute to weight gain, but the evidence is not consistent. In one study, eating lunch 3 hours later in the day than midday was associated with less expenditure of resting energy, decreased fasting carbohydrate oxidation, decreased glucose tolerance, and changes in the circadian rhythm (Bandin, et al., 2014). Limited evidence shows that late-night eating may lead to weight gain (ACDG, 2015). Other evidence shows that eating later in the day may have no overall effect (Ekmekcioglu & Youitou, 2010).

The Effect of Eating Frequency on Appetite Control and Food Intake

AHA meal frequency

The effect of different water immersion temperatures on post-exercise parasympathetic reactivation.

Many processed foods are problematic with respect to excess weight and general health, especially powdered mixes, foods with multiple ingredients, and foods with a long shelf-life (AND, 2014). Ingredients such as relatively large amounts of sugar and relatively less healthy fats (saturated and trans fats) contribute to weight gain. These processed foods tend to have low amounts of fiber, which reduces feelings of satiety relative to whole foods, and can lead to overeating. Unfortunately, convenience, flavoring agents, concentrated energy, and reduced cost make processed foods appealing to many people.

Many processed foods have a concentrated “dose” of sugar and fats as well as small particles which leads to more rapid absorption. The resulting rapidly experienced “reward” resembles the experience of many addicting drugs (Schulte et al., 2015). This leads to overeating followed by symptoms similar to addiction, such as loss of control over consumption, continued use despite negative consequences, and an inability to cut down despite the desire to do so.

Some processed food additives affecting weight include the following:

  • Emulsifiers: Emulsifiers are commonly added to processed foods, especially those with a creamy consistency. Some, for example, carboxymethylcellulose & polysorbate-80, have produced obesity and metabolic syndrome in mice, as well as low-grade bowel inflammation (Chassaing et al., 2015).

Which Foods May Be Addictive The Roles of Processing, Fat Content, and Glycemic Load

The effect of different water immersion temperatures on post-exercise parasympathetic reactivation.

Dietary emulsifiers impact the mouse gut microbiota

Why Hydration Is Important

When notoperly hydrated, thirst can be confused with hunger. This can lead to over-eating and weight gain. Remaining adequately hydrated helps keep the stomach full and avoids this potential misinterpretation (Pan & Hu, 2011).

Keeping Hydrated

While drinking 8 glasses of water a day is often recommended, most people tend to hydrate adequately if they respond to their thirst (IOM, 2014). Patients engaged in a weight-loss program can be instructed to:

  • Try drinking a glass of water when they feel hungry despite adequate food intake.
  • Respond to their thirst throughout the day and not go a long time without fluid intake.

water potassium intake Institute of Medicine

Effects of carbohydrates on satiety differences between liquid and solid food

http://www.andeal.org/ Food and nutrition research

Position of the American Dietetic Association weight management

Billing Possibilities
  • Medicare Annual Wellness Visit (Jortberg, 2013)Registered Dietitian Nutritionists (RDN) can provide the Medicare Annual Wellness Visit under the direct supervision of a physician. This visit could be used to provide Medical Nutrition Therapy and Intensive Behavioral Therapy for obesity.
  • Intensive Behavioral Therapy for Obesity (Jortberg, 2013)Intensive Behavioral Therapy for Obesity provides screening and counseling. Medicare limits this to Part B patients with Obesity (BMI of 30 or higher). Note: This can be performed by an RDN or a physician.Patients can come in up to 22 times in a 12-month period per CMS schedule. Intensive behavior therapy for obesity must be completed within the primary care setting. Therefore, the dietitian would need to be within the primary care office (benefit does not apply to dietitians outside your practice).
  • Medical Nutrition Therapy (Jortberg, 2013)
    RDNs can provide and be reimbursed for Medical Nutrition Therapy (MNT) for:

    • Diabetes self-management
    • Hyperlipidemia
    • Hypertension
    • Overweight/obesity
    • Gestational Diabetes
    • GI disorders
    • GERD
    • Food Allergies

    http://www.eatrightpro.org/

    Weight loss and Nutrition Myths

    Skipping meals or strictly limiting calories is often used to obtain quick weight loss, but this should not be sustained.

    Some diets involve eating just a single food type or a limited selection, which also should not be sustained. A healthy, balanced diet should be recommended.

    The Problem With Fad Diets

    Fad diets often lead to weight cycling, with negative consequences on both mental and physical health.

    • Weight regain is often more weight than was initially lost (USDHHS, 2013).
    • Highly restrictive diets can be dangerous and lead to nutritional deficiencies.
    Diet Plans to Avoid

    Fad diets often convey misinformation. The American Academy of Family Physicians suggests that patients avoid diets or products that:

    • Claim that people lose more than 1-2 pounds per week.
    • Claim that people lose weight without exercise or having to give up calorie-dense foods.
    • Use ‘before’ and ‘after’ photos as proof and post testimonials from ‘real people’ or ‘experts’ who have often been paid.
    • Suggest limiting food choices so much that nutrition is not balanced.

    (AAFP, 2010)

Mediterranean Food List

The Mediterranean diet is characterized by the following:

  • Rich in plant-based foods, including vegetables, fruits, grains, legumes, and nuts
  • Includes fish at least twice a week. Red meat is limited to a few times/month
  • Olive oil (monounsaturated) instead of butter and other saturated fats
  • Herbs and spices instead of salt

SAMPLE MEAL:

  • Seared tuna w/ olive oil
  • Baba ghannouge (eggplant dish)
  • Whole wheat pita bread
  • Tomato gazpacho (cold, tomato-based soup)
  • Glass of red wine
  • Nonfat Greek yogurt
  • Morbidly obese patients, in the MOMANTANA study, followed a Mediteranean diet with no calorie restrictions, but with all the other recommended lifestyle change and weekly behavioral supports. Patients lost more weight in two years than patients receiving conventional medical treatment (-11.3% vs. -1.6% of excess weight, p <0.0044) or bariatric surgery (Burguera et al, 2015). Of patients in the lifestyle change plus Mediterranean diet group, 31.4% were no longer morbidly obese after 6 months.
  • Studies have also found that the Mediterranean diet significantly reduced the incidence of cardiovascular disease (Estruch et al., 2013), mortality, Parkinson’s disease, and Alzheimer’s (Willacy, 2013).

Health effects of Mediterranean Diet

Primary Prevention of Cardiovascular Disease with a Mediterranean Diet

An Intensive Lifestyle Intervention Is an Effective Treatment of Morbid Obesity The TRAMOMTANA Study

DASH diet meals

DASH eating plan

The DASH diet (Dietary Approaches to Stop Hypertension), helps prevent and treat hypertension (Mayo Clinic, 2013). It adheres to the dietary guidelines to keep sodium intake to 2,300 mg per day, or even lower (1500 mg/day) for those over 51 years old, hypertensive, African-American, or diabetic. The DASH diet can be combined with caloric restriction to lose weight. It has the following advantages over simply recommending calorie restriction:

  • Assures a relatively quicker improvement in hypertension; simple calorie restriction improves hypertension more slowly through the weight loss itself
  • Assures optimal nutrition.

The DASH diet is characterized by eating foods that are rich in potassium, calcium, and magnesium, which have been demonstrated to help lower blood pressure, as well as the following:

EATING:

  • Fruits
  • Vegetables
  • Low-fat Dairy
  • Fish
  • Poultry
  • Whole grains
  • Nuts

LIMITING:

  • Red meat
  • Alcohol
  • Added sugar
Dash Diet

SAMPLE MEAL:

  • Chicken Waldorf (low fat version) salad
  • Dinner roll
  • Hard boiled eggs
  • Baby carrots
  • Nonfat milk
  • Cantaloupe
DASH diet_ Healthy eating to lower your blood pressure – Mayo Clinic
Evidence for Effectiveness of High Protein in Weight Loss

High protein diets show promise for weight-loss. Evidence shows that high protein diets:

  • Reduce cardiovascular and metabolic risk in overweight/obese adults (Pasiakos et al., 2015).
  • Have an inverse association with resultant BMI and waist circumference and are positively associated with greater HDL (Pasiakos et al., 2015; Te Morenga et al., 2011).
  • Produce cardiometabolic benefits, greater than or equal to those of low-fat, high-carbohydrate diets (Pasiakos et al., 2015; Te Morenga et al., 2011).
  • Significantly lower weight regain during a 12 month weight loss maintenance study, in comparison to a low protein diet (Aller et al., 2014).
  • May be better at maintaining lean body mass: This was observed during weight loss in two studies of high protein diets (Wycherley et al., 2012 – Macro %s: 35 Protein: 40 Carb: 25 Fat vs. Control 17:58:25; Tang et al., 2013 – 25 Protein:50 Carb 25 Fat vs. Control 15:60:25).
    However, in another study, increasing protein intake in older adults while decreasing energy intake did not preserve lean body mass, strength, or physical performance compared to controls (Batsis, et al, 2015). Strength training, in addition to sufficient protein intake, may be needed to preserve muscle mass.

In other research, a high protein, very low carbohydrate diets produced weight loss of around 2 lbs/week and has shown particular effectiveness in patients with metabolic syndrome, hypertriglyceridemia, and insulin resistance (Logemann, et al., 2014, Pasiakos et al., 2015).

There have been fewer long-term studies regarding high protein diets compared to those for low carbohydrate diets and low fat diets.

How Much Protein?

High protein means relatively higher intake of protein, often around 50% more than the RDA. This comes to around 1.4 g/kg/day instead of the RDA of 0.8 g/kg people of average size, with a little more for men than women. To give an example in terms of common foods:

  • The RDA level of protein for an average sized person is around 50 g/day and would be found in: Chicken (3 ounces), two large eggs, 2 tablespoons of peanut butter, and 8 ounces of yogurt.
  • A high protein level of 60% over RDA for an average sized person is around 80 g/day and would be found in: Chicken (5 ounces), 3 large eggs, 3 tablespoons of peanut butter, 12 ounces of yogurt.
High Protein and Low Carbohydrate

When an individual increases protein, they usually also change their fat and carbohydrate intake and potentially their caloric intake as well. A high protein, low carbohydrate diet has been shown to lower cardiometabolic risk as a result of reduced blood pressure, and improve glycemic regulation and blood lipids (Pasiakos et al., 2015; Wycherley et al., 2012). How much of the effect is from the increased protein and how much is from the lower carbohydrate content is not very clear at this point.

High protein (1.2 to 1.5 g/kg of ideal body weight), combined with very low carbohydrates (20 to 50 g/day), no fats outside of protein foods, and limited caloric intake (800 cal/day) is also called Protein-sparing modified fast (PSMF), which is the diet often used post-weight loss surgery, is effective at producing rapid weight loss of 1 to 3 kg per week while maintaining lean muscle mass (Chang et al, 2014).

One popular diet that is high protein and low carbohydrate is the “Paleolithic Diet” (Mayo Clinic, 2014). so-called because it is described as being more like what our ancient human ancestors consumed than what most people eat. It includes eating fresh lean meats and fish, fruits and vegetables, eggs, nuts and seeds, and olive oil and coconut oil. Foods that are excluded include processed foods, grains, dairy, refined vegetable oils, refined sugar, potatoes, and salt. Because the guidelines for the diet allow for a lot of variation, some people lose weight and others do not. For patients who are following this diet and not losing weight, investigating their food choices is helpful. Recommend that they be sure to consume lots of vegetables and a limited amount of fruits.

Other popular high protein, low carbohydrate diets include the Atkins diet (Stanford Medicine, 2007) and the Zone diet (McDougal, 2016).

Dietary protein intake and renal function

http://www.idealprotein.com/us/physician/logemann-case-study

Paleo diet Mayo clinic

Stanford diet news

Protein sparing diet in DM

Advanced Glycation End Products in Foods and a Practical Guide to Their Reduction in the Diet

Comparison of the effects of 52 weeks weight loss with either a high-protein or high-carbohydrate diet on body composition and cardiometabolic risk factors in overweight and obese males

Normal vs. high-protein weight loss diets in men Effects on body composition and indices of metabolic syndrome

Nutrition and Inflammation in Older Individuals

Comparison of high protein and high fiber weight-loss diets in women with risk factors for the metabolic syndrome

Higher-Protein Diets Are Associated with higher HDL cholesterol and lower BMI

To eat the RDA level of protein, 0.8 g/kg, a patient weighing 100 kg (220 lbs) would eat 80 g/per day (Pasiakos et al., 2015). At the high protein level of 1.4 g/kg, the patient would eat 140 g of protein per day. The following is an example list of a day’s protein at each level:

SAMPLE PROTEIN INTAKE:

Food RDA for Protein
(80 g/day for 100 kg person)
High Protein
(140 g/day for 100 kg person)
Hamburger Patty 3 oz= 21 g 4 oz= 28 g
Steak 4 oz= 28 g 6 oz= 42 g
Peanuts 1/4 C= 9 g 1/2 C= 18 g
Milk 1 C= 8 g 2 C= 16 g
Eggs 2 lg eggs= 12 g 3 lg eggs= 18 g
Cheese 1 oz= 7 g 2 oz= 14 g
Total/day: 85 g 136 g

The role of dietary protein intake in the prevention of sarcopenia of aging.

Low-Carbohydrates

Low Carb DietLow-carbohydrate diets are an effective alternative to calorie restriction weight-loss diets. Characteristics of low carbohydate diets include that they:

  • Are associated with more weight loss and body fat loss than traditional reduced-calorie diets during the first 6 months (AND, 2009).
  • Later produce weight loss closer to that from a simple calorie-restricted diet (AND, 2009) and superior to low fat diets by several pounds on average (Shai et al, 2008).
  • Produce average weight loss of more than 10 kg weight after a year (Jensen et al., 2013).
  • Are more effective than calorie restriction in reducing blood sugar (Yamada et al., 2014).
How Much Carbohydrate?

Low carbohydrate has been defined as 35 to 100 grams per day for weight loss with the higher end being effective for weight maintenance (Last & Wilson, 2006). 90 grams is around 20% of most people’s energy intake. The amount of carbohydrates to consume for weight loss varies with the individual’s size, muscle mass, and activity. A very low carbohydrate diet or ketogenic diet is around 20 gm per day and is described on the following page.

Low Carbohydrates and the Other Macronutrients
  • Low Carbohydrate and High Fat (LCHF): This combination has been shown to be effective and surprisingly, did not produce the harmful metabolic effects that might be expected, especially in the variant with high protein, described previously.
    • In one study, a low (1800) calorie version of this diet produced a mean weight loss of 10 lbs in 6 weeks and did not change serum lipids in an unhealthy way but did increase the size of LDL particles which are less harmful (Hays et al, 2003).
    • In another study, women following a very low carbohydrate/high fat diet with fairly high protein (Atkins diet) lost 10 lbs on the average in a 12 month period, which was around 5 lbs more than several other commonly followed diets: very-low-fat diet (Ornish), balanced macronutrients diet (Zone), and a low-fat/high-fiber diet (LEARN) (Gardner et al, 2007). The experimental group did not experience significantly worse metabolic effects.
  • Low Carbohydrate and High Protein: This combination is effective at weight loss, as was described in the previous section, High Protein.
Less Important Factors for Weight Loss

Factors that are relatively less important for weight loss when eating a low carbohydrate diet include:

  • Type of Carbohydrate: The most important requirement in a low carbohydrate diet for weight loss is that it be low in carbohydrates, rather than focus on type of carbohydrate. The type of carbohydrate eaten is important for many aspects of health: relatively healthier carbohydrates, such as vegetables, contain fiber, important nutrients, and/or produce less risk of spikes in blood sugar. The benefits of relatively healthier carbohydrate include better cardiovascular and gastrointestinal health and better diabetes control. However, the type of carbohydrate eaten has low impact on weight loss. However, if carbohydrates are being limited, it is important to select those that are relatively higher in fiber and denser in nutrients for other health reasons. For example, maintain 5 servings of vegetables per day (Jensen et al., 2014).
  • Glycemic Load: Glycemic load also is not as important for weight loss as low carbohydrate, although it is important to avoid spikes in blood sugar. In contrast to low carbohydrates, research has found no difference between high and low-glycemic-load diets in terms of weight loss (Jensen et al., 2014). Similarly, eating simple vs. complex carbohydrates is not as important for weight loss as eating low carbohydrates.

Very-low-carbohydrate ketogenic diet v. low-fat diet for long-term weight loss a meta-analysis of randomised controlled trials.

Low-Carbohydrate Diets

Ketogenic Diet for Obesity

Effects of a Short-Term Carbohydrate-Restricted Diet on Strength and Power Performance

Short-Term Carbohydrate-Restricted Diet for Weight Loss in Severely Obese Women

Carbohydrate Restriction has a More Favorable Impact on the Metabolic Syndrome than a Low Fat Diet

Short-Term Carbohydrate-Restricted Diet for Weight Loss in Severely Obese Women

Carbohydrate Restriction has a More Favorable Impact on the Metabolic Syndrome than a Low Fat Diet

Thematic Review Series_ Calorie Restriction and Ketogenic Diets_ Ketone body therapy_ from the ketogenic diet to the oral administration of ketone ester

Ketone supplementation decreases tumor cell viability and prolongs survival of mice with metastatic cancer.

A Non-calorie-restricted Low-carbohydrate Diet is Effective alternative for patients with type 2 diabetes

Measuring breath acetone for monitoring fat loss

Do ketogenic diets really suppress appetite A systematic review and meta-analysis

  • Very low carbohydrate diet (12% carbs/59% fat) consumed by overweight subjects with metabolic syndrome for 12 weeks produced significantly more weight loss and reduction in abdominal fat mass than a low fat diet (56% carbs/24% fats) (Volek et al., 2009).
  • When compared to an ad libitum diet with an equivalent high level of protein (30%), a low carbohydrate (4%) diet-induced ketosis (not ketoacidosis) and significantly reduced hunger and appetite relative to a diet consisting of 35% carbohydrate (Johnstone et al., 2008).
  • A review of diet comparisons studies found that very low carbohydrate diets resulted in either better or the same triglyceride levels, HDL-C, blood pressure, and insulin resistance, however, LDL-C tend to be higher (Gardner et al, 2007).
  • A meta-analysis of ketogenic diets found that individuals on a ketogenic low carbohydrate diet were less hungry and had less desire to eat in comparison to when they were in energy balance (Gibson et al., 2014). Individuals on very low-calorie diets were also less hungry and had more feelings of fullness and satiety.
  • Long-term weight loss can be achieved on a ketogenic diet when a healthy diet is also sustained (Bueno et al., 2013; Paoli 2014).
  • Absolute contraindications for ketogenic diets include certain metabolic disorders such as pyruvate carboxylase deficiency, primary carnitine deficiency, and fatty acid oxidation defects (Dhamija et al., 2013).
  • Determining how best to support overweight adults to adhere to lifestyle change SWIFT study
  • food and nutrient intakes

The role of short chain fatty acids in appetite regulation and energy homeostasis

Gene–Environment Interactions Regulating Dietary Fiber Induction of Proliferation and Apoptosis via Butyrate for Cancer Prevention

Researchers are beginning to understand some of the complex mechanisms in the gut microbiome and its role in appetite regulation. Part of this complex picture is the role of carbohydrates that resist digestion and dietary fiber. Non-digestible carbohydrates (i.e. resistant starches, dietary fiber) are fermented in the distal gut (Byrne et al., 2015), producing beneficial metabolites, which have a positive effect on body composition and reduced body weight as shown in preliminary animal research.

Short Chain Fatty Acids (SCFAs)

The beneficial metabolites that are produced from bacterial fermentation of carbohydrates are short chain fatty acids (SCFAs). Consuming non-digestible carbohydrates increases SCFA concentration in the gut, which affects anorexigenic (decreased eating) signals in appetite centers of the brain (Byrne et al., 2015). The following evidence points to the mechanisms in appetite regulation.

  • After consuming an evening meal consisting of fermentable carbohydrates (FCs), circulating peptide YY (PYY, an anorectic hormone) concentrations were increased and ghrelin concentrations (orexigenic hormone) decreased at breakfast (Byrne et al., 2015).
  • Consuming FCs protects against fat mass development and SCFAs protect against diet-induced obesity (Byrne et al., 2015)

Note that specifics of gut hormones and their actions on satiety are explained in greater detail in the Obesity Biology module.

SCFAs and Cancer Prevention: The fermentation of soluble fiber in the gut produces butyrate, an SCFA, which has an effect on the proliferation and apoptosis of colorectal cells. Findings have implicated these bacterial metabolites in tumor suppression within the colon

he Mediterranean diet is rich in plant-based foods and has been shown to help reduce the incidence of cardiovascular disease, mortality, Parkinsons disease and Alzheimers. Any diet that results in reduction of excess weight, is likely to benefit blood pressure. However, the Mediterranean diet uses herbs spices rather than salt and the DASH (Dietary Approaches to Stop Hypertension) Diet specifically limits sodium intake, so weight loss versions of these diets might better benefit a patient with hypertension. These specifications of lowering sodium and substituting low-sodium spices, could be added to any weight-loss diet.

In the typical American diet, added fat accounts for an average for 24 to 32% of energy, which is within the current FDA recommendation of around 20 to 35% of total calories from fats and oils, primarily from the more healthy monounsaturated and polyunsaturated fats (USDA, 2015). However, some patients, like Ms. Watson, could lower their fat intake to lose weight and still fall within the current FDA guidelines. Keep in mind that low fat diets, on average, are not as effective for long term weight loss as some others, such as low carbohydrate and Mediterranean diet, but do tend to produce some weight loss (Shai et al., 2008).

Fats have the greatest amount of food energy per gram (g):

  • Fats: 8.8 kcal/g
  • Proteins and most carbohydrates: 4.1 kcal/g

(Kelso, 2014).
Fat reduction for weight loss should be limited and selective, focusing on reducing the less healthy fats. Fats contribute to feeling full and have other beneficial effects. The emphasis should be on reducing unhealthy fats, especially (manufactured) trans fats and hydrogenated or partially hydrogenated fats and the less healthy saturated fats, such as foods fried in saturated fats. Instead, maintain (or increase if needed) relatively healthy fats, like those with omega 3 fatty acids and polyunsaturated fat.

http://breakingmuscle.com/nutrition/the-right-way-to-lose-fat-what-to-eat

Academy of Nutrition and Dietetics. Position of the American Dietetic Association: Weight Management. Journal of the Academy of Nutrition and Dietetics. 2009; 109: 330-346. Available at: http://www.andeal.org/files/Docs/WM%20Position%20Paper.pdf
American Heart Association. The American Heart Association’s Diet and Lifestyle Recommendations. . 2014; February: . Available at:http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyEating/The-American-Heart-Associations-Diet-and-Lifestyle-Recommendations_UCM_305855_Article.jsp Accessed on: 2015-03-20.
Dietary Guidelines Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. health.gov. 2015. Available at: http://health.gov/dietaryguidelines/2015-scientific-report/ Accessed on: 2015-02-24.
Gregor MF, Hotamisligil GS. Inflammatory mechanisms in obesity. Annu Rev Immunol. 2011; 29: 415-45. Available at:http://www.ncbi.nlm.nih.gov/pubmed/21219177 Accessed on: 2015-08-27.
Harcombe Z, Baker JS, Cooper SM, et al. Evidence from randomised controlled trials did not support the introduction of dietary fat guidelines in 1977 and 1983: a systematic review and meta-analysis. Open Heart. 2015; 2: . Available at:http://openheart.bmj.com/content/2/1/e000196.full Accessed on: 2015-02-15.
Jensen M, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults . Journal of the American College of Cardiology. 2014. Available at: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437739.71477.eeAccessed on: 2015-01-21.
Kelso T. The right way to lose fat: what to eat . Breaking Muscle. 2014. Available at: http://breakingmuscle.com/nutrition/the-right-way-to-lose-fat-what-to-eat Accessed on: 2014-12-16.
Samra RA . Fats and Satiety . Fat detection: taste, texture, and post ingestive effects . 2010; Chapter 15: . Available at:http://www.ncbi.nlm.nih.gov/books/NBK53550/ Accessed on: 2015-03-23.
Shai I, Schwarzfuchs D, Henkin Y, et al.. Weight loss with a low-carbohydrate, Mediterranean, or low fat diet. New England Journal of Medicine. 2008; 359(3): 229-241. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMoa0708681 Accessed on: 2015-03-11.
Teng KT, Chang CY, Chang LF. Modulation of obesity-induced inflammation by dietary fats: mechanisms and clinical evidence. Nutrition Journal. 2014; 13:12: . Available at: http://www.nutritionj.com/content/13/1/12 Accessed on: 2015-08-27.
US Department of Health and Human Services, US Department of Agriculture. Dietary Guidelines for Americans 2015-2020. health.gov.December 2015. Available at: http://health.gov/dietaryguidelines/2015/guidelines/acknowledgments/ Accessed on: 2016-01-08.
Wells HF, Buzby JC. Dietary assessment of major trends in U.S. food consumption, 1970-2005. ERS Report Summary . 2008. Available at:http://www.ers.usda.gov/publications/eib-economic-information-bulletin/eib33.aspx Accessed on: 2015-03-20.
Academy of Nutrition and Dietetics. Position of the American Dietetic Association: Weight Management. Journal of the Academy of Nutrition and Dietetics. 2009; 109: 330-346. Available at: http://www.andeal.org/files/Docs/WM%20Position%20Paper.pdf
American Heart Association. The American Heart Association’s Diet and Lifestyle Recommendations. . 2014; February: . Available at:http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyEating/The-American-Heart-Associations-Diet-and-Lifestyle-Recommendations_UCM_305855_Article.jsp Accessed on: 2015-03-20.
Gardner C, Kiazand A, Alhassan S, et al.. Comparison of the Atkins, Zone, Ornish, and LEARN Diets for Change in Weight and Related Risk Factors Among Overweight Premenopausal Women The A TO Z Weight Loss Study: A Randomized Trial. JAMA. 2007; 297(9): 969-977. Available at: http://jama.jamanetwork.com/article.aspx?articleid=205916 Accessed on: 2015-12-17.
Gregor MF, Hotamisligil GS. Inflammatory mechanisms in obesity. Annu Rev Immunol. 2011; 29: 415-45. Available at:http://www.ncbi.nlm.nih.gov/pubmed/21219177 Accessed on: 2015-08-27.
Harcombe Z, Baker JS, Cooper SM, et al. Evidence from randomised controlled trials did not support the introduction of dietary fat guidelines in 1977 and 1983: a systematic review and meta-analysis. Open Heart. 2015; 2: . Available at:http://openheart.bmj.com/content/2/1/e000196.full Accessed on: 2015-02-15.
Jensen M, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults . Journal of the American College of Cardiology. 2014. Available at: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437739.71477.eeAccessed on: 2015-01-21.
Kelso T. The right way to lose fat: what to eat . Breaking Muscle. 2014. Available at: http://breakingmuscle.com/nutrition/the-right-way-to-lose-fat-what-to-eat Accessed on: 2014-12-16.
Mayo Clinic Staff . Weight loss: What are the options?. Mayo Clinic. 2015. Available at: http://www.mayoclinic.org/healthy-lifestyle/weight-loss/in-depth/weight-loss/art-20048466?pg=2 Accessed on: 2016-05-24.
Rautiainen S, Wang L, Lee IM, et al. Dairy consumption in association with weight change and risk of becoming overweight or obese in middle-aged and older women: a prospective cohort study. The Journal of Clinical Nutrition. 2016; 103(4): 979-988. Available at:http://ajcn.nutrition.org/content/103/4/979.abstract
Samra RA . Fats and Satiety . Fat detection: taste, texture, and post ingestive effects . 2010; Chapter 15: . Available at:http://www.ncbi.nlm.nih.gov/books/NBK53550/ Accessed on: 2015-03-23.
Shai I, Schwarzfuchs D, Henkin Y, et al.. Weight loss with a low-carbohydrate, Mediterranean, or low fat diet. New England Journal of Medicine. 2008; 359(3): 229-241. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMoa0708681 Accessed on: 2015-03-11.
Teng KT, Chang CY, Chang LF. Modulation of obesity-induced inflammation by dietary fats: mechanisms and clinical evidence. Nutrition Journal. 2014; 13:12: . Available at: http://www.nutritionj.com/content/13/1/12 Accessed on: 2015-08-27.
US Department of Health and Human Services, US Department of Agriculture. Dietary Guidelines for Americans 2015-2020. health.gov.December 2015. Available at: http://health.gov/dietaryguidelines/2015/guidelines/acknowledgments/ Accessed on: 2016-01-08.
Wells HF, Buzby JC. Dietary assessment of major trends in U.S. food consumption, 1970-2005. ERS Report Summary . 2008. Available at:http://www.ers.usda.gov/publications/eib-economic-information-bulletin/eib33.aspx Accessed on: 2015-03-20.
Yakoob MY, Shi P, Willett WC, et al. Circulating biomarkers of dairy fat and risk of incident diabetes mellitus among US men and women in two large prospective cohorts. Circulation. 2016; doi: 10.1161/CIRCULATIONAHA.115.018410: . Available at:http://circ.ahajournals.org/content/early/2016/03/22/CIRCULATIONAHA.115.018410.abstract?sid=d5affc9c-fbb1-4a44-9c29-7c53955148adAccessed on: 2016-04-19.
  • Low-fat diets, in combination with energy reduction, produce weight loss similar to low carbohydrate diets in the short term (Jensen et al., 2014).
    • After 2 years, however, low-carbohydrate and Mediterranean diets produce slightly more weight loss than low fat diets (Shai et al., 2008).
  • Low fat diets are effective if they do not dip below the low end of the RDA for fat, which is 20 to 35% of calories (USDA, 2015).
    • Lower amounts of fat can result in not feeling full, because fat aids in feelings of satiety late in the digestion process (Samra, 2010). While outcomes of specific diets vary, recommending that patients follow a healthy-fat / high-protein, low-carbohydrate diet/ high fiber diet might be a good alternative for them to achieve overall weight loss (Gardner et al., 2007).
  • Low fat and low calorie diets plus recommended physical activity reduce factors promoting cardiovascular disease and diabetes (AND, 2009).
  • Low fat diets with are also very low in carbohydrates can have a beneficial effect on insulin resistance (Gardner et al., 2007).
  • Modifying dietary fats improves metabolic dysfunction and insulin resistance that arises due to inflammatory responses (Teng et al, 2014). Obesity causes a low-grade inflammatory response in metabolic tissues, such as adipose tissue, liver, muscle, pancreas, and brain (Gregor & Hotamislagil, 2011).
More fat is sometimes good!
  • Relatively higher levels of dairy fats has been associated with less weight gain (Rautiainen et al, 2016) and decreased risk of diabetes(Yakoob et al, 2016) in two major studies.
  • Increasing foods containing linolenic acid, such as deep sea fish like salmon, may be beneficial for comorbidities, however, weight loss is more effective at reducing obesity-related inflammation.

Circulating Biomarkers of Dairy Fat and Risk of Incident Diabetes Mellitus Among US Men and Women in Two Large Prospective Cohorts

airy consumption in association with weight change and risk of becoming overweight or obese in middle-aged and older women

FOUR BASIC STEPS ARE FOLLOWED IN MOTIVATIONAL INTERVIEWING:

  1. Engaging – Gain the patient’s trust and interest in making a change
  2. Focusing – Help the patient focus on the problem
  3. Eliciting – Use questions to guide the patient in stating feelings and goals
  4. Planning – Facilitate the patient in establishing a plan for achieving the goals

Using motivational interviewingin routine care

In a patient-centered, motivational approach, the provider guides the patient rather than tells the patient. These non-directive approaches differ from advice-giving (directive) by healthcare professionals. Instead, the healthcare provider recognizes the expertise of the patient on his or her own motivations. The provider is only somewhat directive as they guide the patient to examine and resolve any ambivalence about the problem (Miller & Rollnick, 2012).

  • Guiding: A little directing is still needed in this approach, but it takes the form of facilitation and guidance. Guide patients toward being introspective, discuss certain topics that are likely to lead toward readiness for change, and resolve any ambivalence about it. Use gentle, guiding questions to direct.
  • Non-Directive or Patient-Centered: Be non-directive or patient-centered by allowing patients to come up with their own motivations, goals, and ambivalent feelings surrounding their problem behaviors. They can even develop their own plan to resolve their problems.
  • A directive, motivational approach may not work for every individual. Some patients may do better with more guidance. In some cultures, people may prefer to receive advice from an authority figure rather than participate in decision-making. However, the stage of acculturation varies among individuals who have moved into a culture that is new to them. Assumptions about preferences based on ethnicity or race may not be accurate for a particular individual.The same interventions work for all racial-ethnic groups. At the same time, differences in individual needs due to cultural, ethnic, and racial differences should be elicited from the patient and addressed.
The use of empathy and affirmations in patient interviews is important in gaining patient connection and trust. These skills are useful in several steps of the motivational technique.
Empathy

DEFINITION Expressing an understanding of things as the patient feels, sees, and thinks about them (Rollnick et al., 2008). Empathy is also communicated through an expression of caring in your eyes, facial expression, tone of voice, and body language.

Rationale: When people feel empathy from someone, they feel understood and validated (Rollnick et al., 2008). When patients experience empathy from a provider, they are more likely to open up to the provider and to their own experience. They will be more comfortable examining their ambivalence, for example, about making a lifestyle change to lose weight. They will also be more open to gentle challenges from the provider.

Affirmations

DEFINITION A supportive statement made by the provider in response to what a patient has said that verifies and acknowledges the patient’s attempts to change their behavior (Miller & Rollnick, 2012).

Rationale: Failure to achieve weight loss goals can lead to a downward spiral of confidence and self-esteem accompanied by weight gain (Miller & Rollnick, 2012). A pattern of weight cycling up and down often results. This can be frustrating for both the clinician and patient. Use of affirmations can increase patients’ confidence in their ability to make healthy changes. These statements show that the provider recognizes patient strengths, efforts, and successes in making the long-term change that is needed

Empathy and affirmations are especially helpful early in the Engaging step. This is when you are trying to connect with the patient and gain their trust and interest in making a change.

Connecting with the patient is also important later in the patient interview during the Eliciting step. This is when you guide the patient in stating their thoughts and feelings.

Normalizing

DEFINITION Communicating that the patient’s experience or feelings are typical of many people.

Rationale: “Normalizing” helps communicate to patients that they are not alone in their experience and struggles, including feelings of ambivalence and resistance to change. Normalizing helps patients understand that many people have difficulty changing their behaviors and beliefs (Westra, 2012).

Reassurance

DEFINITION Communicating that a situation is safe or a that a positive outcome is likely.

Rationale: Reassurance that other patients have succeeded despite similar difficulties or feelings of ambivalence helps patients believe that they can succeed, thus building confidence.

Motivational Interviewing in the Treatment of Anxiety

Motivational Interviewing

Motivational Interviewing in Health Care

Open-ended questions are especially helpful to achieve the Focusing step after you have engaged the patient and want to help the patient focus on the problem. But also use open-ended questions in all steps of Motivational Interviewing.

Some topics that can be discussed using open-ended questions include asking the patient:

  1. What they would like their weight and health to be in the future
  2. To review his or her eating on a typical day
  3. Asking their thoughts and feelings on diet assessment results

Determining your patient’s readiness for change is important to provide tailored treatment, which can improve chances of weight-loss success. Directly asking their readiness to change can be quick and effective:

Miller WR, Rollnick W. Motivational interviewing: preparing people to change. University of New Mexico. 1998.

Readiness to Change Ruler

Assessing Readiness

Patients Who Are Not Ready

Patients who are not ready to change can have interventions that focus on helping them move to the next stage of change by:

  • Increasing hope
  • Building self-confidence
  • Exploring their personal barriers

Keep in mind that many people already want to lose weight and eat healthier, but are discouraged because of past attempts and failures. So in addition to the motivation to try again, they need confidence and hope. Communicating your certainty that weight loss if possible can help build hope.

Use Reflective Listening

DEFINITION Listening carefully to what the patient says, then summarizing or paraphrasing it.

Rationale: Reflective listening shows them that you are listening and trying to understand them. It is one of the most powerful techniques for building rapport.

Reflective listening also demonstrates to the patient whether the doctor accurately understands the patient’s view and gives the patient a chance to clarify your understanding. Listening carefully to the patient will help you know what is working for them and what is not.

Reflections should be statements that mirror the content or emotional tone of the patient’s words. They should not be questions.

Reflective statements should be non-judgmental, even if you do not agree with the patient. To help you do this sincerely and honestly, add phrases such as, “It sounds like you feel…” or, “So, the way you see it is…”

  • Pay more attention to the patient’s statements about being willing to change and less to their talk about not changing, without ignoring their concerns regarding not changing.
  • Occasionally reflecting emotions, especially those that are apparent but not spoken, can be a powerful motivator.

Goals work best if they include several characteristics, represented by the acronym SMART: specific, measurable, achievable, relevant and time-bound.

Once a patient acts resistant, the best approach is to not challenge it (Miller & Rollnick, 2012). Confronting a patient’s resistance, can serve to increase it. Resistance may show up in different forms:

  • “No” Talk: When a patient resists any proposed treatment suggestions.
  • “Sustain” Talk: When patients describe their reasons to sustain an unhealthy behavior.

Responding to “No” Talk

A patient may reject all suggestions for addressing weight problems. One possible response is to acknowledge the patient’s frustrations or statements of other emotions.

Engage:
Building rapport through showing concern for the patient’s well-being
Focus:

Bringing up the topic of patient weight

Determining readiness to change

Elicit Motivational Statements:

Using open-ended questions

Using reflective listening and summarizing a patient’s most important motivators throughout motivational counseling

Using affirmations, normalizing, reassurance, and empathy to engage the patient and to respond. These skills are used when eliciting their feelings.

Tailoring motivational dialogue to the patient’s stage of change regarding weight loss

Plan for Change:
Tailoring weight management plans by stage of change

As you watch the video, notice how the provider uses various techniques from motivational interviewing (MI) that have been desribed in this module thus far, such as empathy, reflective listening, and open-ended questions, to achieve the four steps of MI:

  1. Engage
  2. Focus
  3. Elicit
  4. Plan

When engaging the patient to start a discussion of their weight, which is a sensitive topic for many people, first build rapport and ask permission to avoid setting up patient resistance.

Build Rapport

Establishing rapport decreases defensiveness and increase openness to the possibility of change. Expressions of acceptance and affirmation are important parts of building rapport (Rollnick et al., 2008). Make sure to:

  • Be reassuring: Reassurance that you are not going to insist on immediate and drastic lifestyle changes — you just want to talk — may also help.
  • Use non-threatening body language: Pay attention to your body language. Adopt open, non-authoritarian body language. For example, sit at the same level as the patient, maintain regular eye contact, keep your chest and hands open, and do not cross your legs. Be relaxed while professional — the demeanor will likely be contagious.
Ask Permission

Asking permission engages patients by getting them to “buy-in” to the process. This approach helps the patient realize the they have a say in what happens.

When giving factual advice, asking patients their response to it helps engage them.

Motivational interviewing in Health care

Minimization of his weight problem could come from lack of awareness, denial, or resistance. Reasons for resistance or denial include not wanting to face painful criticism from self or others, frustration at failed weight attempts, or embarrassment in discussing weight with others.

Keeping these reasons in mind, how would you respond to Mr. Murphy’s statement that he doesn’t think of himself as overweight, even though he is obese according to his BMI?

This approach uses the Motivational Interviewing approach of “normalizing” the patient’s experience to lower their embarrassment, self-criticism, and defensiveness. This approach also asks patient permission to discuss the topic.

Patients do not have to be 100% motivated or confident in their ability to change in order for change to occur. Just talking about it can help patients find motivation, gain confidence, and be more receptive to a recommendation for intensive treatment.

Describe or elicit from the patient things to build their confidence including:

  • Other health habits they have changed successfully
  • Your experience with watching patients who were successful in weight loss
  • Your confidence that evidence-based models are effective when followed
Eliciting

Elicit motivational statements, that is emotions or feelings related to his or her inner motivations for making the change (Rollnick et al., 2008), by asking questions.

How would your life be different if you lost weight?

Reinforcing

Reinforce motivational statements by reflecting them back to the patient, nodding, or including them in a summary (Rollnick et al., 2008).

So, you would feel pretty good to know you could get back in shape.

Pausing

Pauses are a very powerful way to draw people out without asking questions. After making a reflective statement, pause and wait patiently. Many people will fill the pause.

Exploring Values

Helping the patient explore his or her values can stimulate motivation for change (Rollnick et al., 2008). Have the patient explore his or her ideal self — this will bring incongruities to light.

What is your most important reason for losing weight?

Keep in mind that motivational statements are about the patient’s motivation for change, not the doctor’s.

Elicit and Facilitate Articulation of Ambivalence

Help the patient explore, articulate, and clarify any ambivalence he or she may have about changing their eating and exercise habits. One way ambivalence can be resolved is when a person realizes that the long-term outcome is more valuable than short term benefits (Rollnick et al., 2008; Miller & Rollnick, 2012). For example, a patient may realize that the long-term outcome of losing weight and being healthy is more valuable than the short-term pleasure of overindulging.

Facilitate Exploration of Both Sides of the Ambivalence

This approach, Decisional Balancing, explores how each side has benefits and costs and helps clarify the patient’s confused thoughts and feelings. Exploring the pluses of continuing the unhealthy behavior before talking about the minuses lowers patient resistance (Rollnick et al., 2008; Miller & Rollnick, 2012). Focusing on the urgency of the problem or just talking about the benefits of change tends to increase resistance.

You probably get something out of avoiding weight loss. Can you tell me about that?

  • Highlight discrepancies in what the patient says in order to produce internal tension that can lead to change.

Ambivalence comes from having conflicting goals (Rollnick et al., 2008). A patient may want the immediate satisfaction of overindulging in food, but also want the benefits of weight loss.

Ambivalence, or a lack of resolve, is an obstacle to change that must be resolved (Rollnick et al., 2008). Helping a patient identify ambivalence can create internal tension, which can lead to resolution and change.

Engage:
Creating an atmosphere in which the often sensitive topic of weight can be discussed
Focus:
Raising the patient’s awareness of his or her’s weight problem by dealing with denial or lack of awareness
Elicit Motivational Statements:

Assessing the patient’s motivation to improve weight or change eating and exercise habits

Evaluating the patient’s ambivalence about changing behaviors to improve health

Plan for Change:
Facilitating the patient in developing a plan for changing their eating patterns
Understanding Frame of Reference

It is important to understand the patient’s frame of reference (Rollnick et al., 2008) when assessing their weight and health problems. This is primarily accomplished through the basic skill of reflective listening (discussed earlier in the module).

Labeling weight as a problem, before the patient comes to view it that way, may work against establishing rapport; rather, the provider can simply describe the behavior instead. An example of this can be saying “How long have you been this weight?” instead of “How long have you had this problem?”

Identify barriers for the patient to making the recommended lifestyle changes or treatments, such as financial limitations, and then support the patient in brainstorming about solutions.

Direct patients to interventions that are more likely to be successful in their community. For example, in many African-American communities, church-based weight-loss programs have proven effective (Kim et al., 2008).

The WORD (Wholeness, Oneness, Righteousness,

 

Question 1 of 1

Obese patients may experience emotional and physicial discomfort if medical practices cannot accomodate their size. Waiting area chairs, exam tables, and blood pressure cuffs may not be large enough or scales may not support their weight or go high enough.

Reframing

Reframing is an approach that changes perspective, usually from looking on the dark side to looking on the bright side. It can help when a patient seems stuck on a negative point of view. Invite patients to look at something from a new perspective or with a new organization: one that helps them get unstuck and move toward change (Rollnick et al., 2008; Miller & Rollnick, 2012). Emphasize the positives of the new perspective while acknowledging any downfalls.

It may seem like all those weight-loss diets were “failures.” But if you think about it, with each attempt, you learned something important about yourself and about what helps you live a healthy lifestyle.

Once a patient acts resistant, the best approach is to not challenge it (Miller & Rollnick, 2012). Confronting a patient’s resistance, can serve to increase it. Resistance may show up in different forms:

  • “No” Talk: When a patient resists any proposed treatment suggestions.
  • “Sustain” Talk: When patients describe their reasons to sustain an unhealthy behavior.

Responding to “No” Talk

A patient may reject all suggestions for addressing weight problems. One possible response is to acknowledge the patient’s frustrations or statements of other emotions.

It sounds like you’ve had a lot of disappointments trying to lose weight. I can see why it is difficult to think about trying again. Can we work together to find something you can do now, no matter how small? The important thing is to get started in a healthy direction.

Responding to “Sustain” Talk

When a patient describes a need to maintain current eating habits, try to discover their motivation to continue the unhealthy behavior. First, acknowledge that their feeling is valid. Then turn the patient’s “Sustain Talk” into “Change Talk” by asking questions about the opposite of their sustaining motivation.

I understand your concern about risks with medications and that the pleasure of eating makes it difficult to change what you eat. On the other hand, what motivation do you have toward making some changes to lose weight?

Another technique for de-escalating resistance, called “rolling with the resistance,” is to agree with the patient’s resistance rather than proposing solutions. Paradoxically, this agreement may lead to patients coming up with solutions that counter their own beliefs, which can initiate change.

So, based on your past experience, you are pretty sure that failing to lose weight would be more than you can bear.

Responding to Discord

Although things ended up going fairly well in the dialogue with Mr. Harris, some physicians are worried they might offend a patient and harm their relationship by bringing up a weight problem. This may or may not happen, but in the event that it does, there are some things you can do.

Signs of discord include the patient interrupting you, changing the subject, or discounting things you say. Discord will result in talking at cross purposes and not being in tune with each other (Miller & Rollnick, 2012). If you notice discord in your interactions, try one of the following:

You’re right. No one does know how hard it is for you. Only you know. And I’m sorry to hear how much of a struggle it is. [Empathy]

Acknowledge the Patients’ Other Issues

Patients may be more concerned about other issues in their lives, that they may perceive as more important than their weight (Emmons & Rollnick, 2001). Or other issues may be preventing them from addressing their weight.

“I understand that it can be hard to focus on your health when you are out of work and worried about your finances. [Acknowledging patient’s problems] Let’s think about what you can do even with all that is going on in your life.”

Consider Harm Reduction

For patients with serious comorbid conditions who seem resistant to change, a limited change for the purpose of harm reduction may be appropriate

Would you consider just cutting down on sugary drinks as a first step? [Suggestion for harm reduction]

Motivational Interviewing in Health Care Settings

Make Stage of Change Appropriate Recommendations

Advise patients lacking motivation to at least avoid further weight gain

Focus on Weight-Related Comorbidities

Treat their risk factors and obesity-related comorbidities

The best approach, for your high blood presssure, would be both medication and weight loss, but for now we can start the medication and build toward weight loss.

Focus on Eliminating Barriers

Even if patients are not ready to pursue weight loss, consider whether there are contributing psychosocial factors that might be addressed at this time. For example, depression or contributing medical factors, such as weight gain from medications or hypothyroidism or sleep apnea, could be the focus until the patient is ready to address weight loss.

It is difficult to change your diet when you are unsure of your potential for success. Can we talk about reasons you might be feeling this way?

Engage:
Looking at the problem from the patient’s perspective
Focus:
Avoiding resistance
Elicit Motivational Statements:
Addressing resistance and discord
Plan for Change:
Responding when patients still are not motivated to lose weight

 

Good choice. Asking permission to discuss weight will help build rapport.

Review Polycystic ovary syndrome a complex condition impacting health across the lifespan

If you are interested in talking about losing weight, we could talk about ways to do it that would not cost much time. It would reduce health risks and probably give you more energy to keep up with your daughter. Would you be open to trying to lose weight? [Determining patient readiness.]

The following “trick” helps the provider assess the motivation that the patient already has. The trick is that it gets the patient to say something positive about their desire for change, even if their motivation is low.

On a scale of 1 to 10, how confident are you that you could begin making changes to your diet? [Assessing confidence]

No, I am interested in why you did not rate yourself lower. You must have at least some motivation and confidence or you would have said “1.”

the 3rd step of Motivational Interviewing which is to evoke patient feelings and eliciting their thoughts. In this case, the provider is focused on thoughts regarding Ms. Benson’s personal barriers to weight loss and then facilitating the brainstorming of solutions

You said you have had trouble with losing weight since you stopped smoking. Many people do gain some weight, but it is possible to lose weight after quitting. Tell me more about the things in your life that are getting in the way.

It sounds like you are responsible for quite a lot! But, keep in mind, you need to take care of yourself, too, so you can be there for your family. [Pauses]

[Summarizing] It is, absolutely! So you are starting to think about losing weight and feeling motivated. You are heading in a good direction! There are some weight-loss programs that provide support and have been shown to make a difference for many people trying to lose weight. Can we talk about them?

Collaborate with the Patient to Create a Personalized Plan for Change

Ms. Benson is guided to come up with her own plan for change, which is step four and the final step of motivational interviewing. In the following dialogue, the provider elicits a plan from the patient for a limited period, from a couple of weeks up to around 90 days. The time frame depends upon her support system and when the provider will next see the patient.

Tell me, what steps are you ready to take in the next month towards improving your diet and activity level?

Cutting your portion sizes down sounds like a great start. Part of successful weight loss for most people is getting enough support in making the kind of lifestyle changes we’ve been talking about. How much support do you have already?

https://www.accessdata.fda.gov/scripts/cder/rems/index.cfm?event=IndvRemsDetails.page&REMS=45  < FDA REMS site

http://www.qsymiarems.com/ QSYMIA REMS site

QSyMIA full-prescribing-information

qsymia-medication-guide

qsymia-full-prescribing-information

dear-healthcare-provider-letter QSYMIA letter

dosing-management-checklist QSYMIA

patient-counseling-tool QSYMIA

risk-of-birth-defects-with-qsymia-patient-brochure

http://www.cdc.gov/ncbddd/birthdefects/nbdps.html < CDC birth defects site

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National north american AED pregnancy registry

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Zika Virus, Aging, nutrition, diseases and discussions regarding healthy life choices and physical activity. Alternative medicine and mainstream medicine included!