1 Lifestyle InterventionHow Do We Treat Obesity? Lifestyle Intervention

2 Why Is Lifestyle Weight Management Important?Improved metabolic control Lower fasting blood glucose and prevent T2D Lower blood pressure and lipid profile Reduce need for pharmacologic therapy for metabolic complications associated with obesity Improved quality of life Less musculoskeletal weight-bearing joint pain Improved GERD, OSA, reactive airway disease Increased life expectancy Lower incidence of certain cancers GERD = gastroesophageal reflux disease; OSA = obstructive sleep apnea; T2D = type 2 diabetes. Lean ME, et al. Diabet Med. 1990;7: Wing RR, et al. Arch Intern Med 1987;147: Schotte DE, et al. Arch Intern Med. 1990;150: Dattilo AM, Kris-Etherton PM. Am J Clin Nutr. 1992;56: Bianchini F, et al. Obesity Rev. 2002;3:5-8. Wadden TA, et al. Obesity (Silver Spring). 2011;19:

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4 Components of Therapeutic Lifestyle ChangeNutrition Reduced calorie meal plans Healthy eating patterns Physical activity Healthy behavior habits Limited alcohol consumption Sufficient sleep Stress reduction (to include behavioral therapy as necessary) Handelsman Y, et al. Endocr Pract. 2015;21(suppl 1):1-87.

5 Intensification of Lifestyle Therapies to Achieve Weight Loss GoalsSimple advice to lose weight in doctor’s office Internet programs or self-help books Advice from dietitian Structured programs (Weight Watchers, YMCA, telecommunication) Multidisciplinary structured programs Physician-driven individualized structured programs INTENSIFICATION Impart skills and behavior change to induce and maintain weight loss

6 Lifestyle InterventionNutrition

7 Reduced Calorie Meal PlansRecommendation General eating habits Regular meals and snacks; avoid fasting to lose weight Plant-based nutrition (high in fiber, low calories, low glycemic index, high in phytochemicals/antioxidants) Understand Nutrition Facts Label information Incorporate beliefs and culture into discussions Informal physician-patient discussions Use mild cooking techniques instead of high-heat cooking A negative energy balance is necessary to achieve weight loss Gonzalez-Campoy JM, et al. Endocr Pract. 2013;19(suppl 3):1-82.

8 Nutritional ComponentsRecommendation Carbohydrates Understand health effects of the 3 types of carbohydrates: sugars, starch, and fiber Target 7-10 servings per day of healthful carbohydrates (fresh fruits and vegetables, pulses, whole grains) Lower-glycemic index foods may facilitate glycemic control:* multigrain bread, pumpernickel bread, whole oats, legumes, apple, lentils, chickpeas, mango, yams, brown rice Fat Eat healthful fats: low-mercury/low-contaminant-containing nuts, avocado, certain plant oils, fish Limit saturated fats (butter, fatty red meats, tropical plant oils, fast foods) and trans fats Use no- or low-fat dairy products  Protein Consume protein from foods low in saturated fats (fish, egg whites, beans) Avoid or limit processed meats Micronutrients Routine supplementation not necessary except for patients at risk of insufficiency or deficiency Chromium; vanadium; magnesium; vitamins A, C, and E; and CoQ10 not recommended for glycemic control *Insufficient evidence to support a formal recommendation to educate patients that sugars have both positive and negative health effects. Gonzalez-Campoy JM, et al. Endocr Pract. 2013;19(suppl 3):1-82.

9 Macronutrient CompositionMeal patterns enriched in the following are associated with a decrease in insulin sensitivity Total fat Saturated fat Trans-fat Refined grains Meal patterns enriched in the following are associated with an increase in insulin sensitivity Fiber Fruits/vegetables Polyunsaturated fats Monounsaturated fats Whole grain Gonzalez-Campoy JM, et al. Endocr Pract. 2013;19(suppl 3):1-82. Garvey WY, Lara-Castro C. J Clin Endocrinol Metab. 2004;89:

10 Features of Different Types of Meal PlansCalories Composition Recommended food choices Dietary Approaches to Stop Hypertension (DASH) kcal/day depending on individual needs ≤27% fat calories. ≤6% saturated fat calories. ≤150 mg/day cholesterol. ≤3 g/day sodium. Fruits, vegetables, and low-fat dairy foods. Low- carbohydrate (Atkins) No restrictions 20 g/day carbohydrates during 2-month induction phase, with gradual increase to ≤120 g/day carbohydrates. Vegetarian sources of fat and protein preferred. Avoid trans fat. Low-fat Women: kcal/d Men: 1800 kcal/d 30% fat calories. ≤10% saturated fat calories. ≤300 mg/day cholesterol. Low-fat grains, vegetables, fruits, and legumes. Limit sweets and high-fat snacks Mediterranean ≤35% of calories from fat Vegetables , poultry, and fish. Main fat source: g/day olive oil and 5-7 nuts (<20 g/ day). Limited red meat. Appel LJ, et al. N Engl J Med. 1997;336: Shai I, et al. N Engl J Med. 2008;359:

11 Weight Change by Meal Plan TypeAdherence Is More Important Than Meal Plan Type for Weight Loss Success Weight Change by Meal Plan Type  Weight (kg) Months on Diet P=0.89 P=0.76 P=0.40 Although different diet types did not yield significantly different weight loss, greater diet adherence was significantly associated with weight loss (r=0.60; P<0.001), and participants in the top tertile of lost an average of ~7% of baseline body weight. Dansinger M. JAMA. 2005;293:43-53.

12 Effect of Low-Fat and Low-Carbohydrate Meal Plans on Weight Over 2 Years* * Adults with Obesity (N=307) -2 Low-fat meal plan Low-carbohydrate meal plan -4 -6  Weight (kg) -8 -10 -12 -14 3 6 12 24 Months Foster GD, et al. Ann Intern Med. 2010;153:

13 Lipid Effects of Low-Fat and Low-Carbohydrate Meal PlansAdults with Obesity (N=307) Low-fat meal plan Low-carbohydrate meal plan -20 -40 -50 -30 -10 6 12  Triglycerides (mg/dL) Months 24 3 * 6 12 Months 24 3 -4 -8 -10 -6 -2  VLDL (mg/dL) 2 -12 * † 6 12 Months 24 3 -12 -18 -6  LDL-C (mg/dL) * 6 12 Months 24 3 10 -5 5  HDL-C (mg/dL) * † * P<0.001 between groups. † P<0.01 between groups. Foster GD, et al. Ann Intern Med. 2010;153:

14 Healthy Mediterranean Style Eating PatternFood Group Recommended Consumption Vegetables 2.5 c-eq/day Fruits Grains 6 oz-eq/day Whole grains ≥3 oz-eq/day Dairy 2 c-eq/day Protein 6.5 oz-eq/day Seafood 15 oz-eq/week Meat,* poultry, eggs 25 oz-eq/week Nuts, seeds, soy 5 oz-eq/week Oils 27 g/day Red meat, high fat dairy, processed foods Fish, poultry, eggs, yogurt Fruits, vegetables, whole grains, olive oil, nuts, legumes *Lean meat preferred. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th Edition. December Available at

15 Effects of Different Diets on WeightDietary Intervention Randomized Control Trial (DIRECT) Study Design 322 overweight or obese adults (85% men) 2-year study duration Randomized, controlled design Diet group Calorie Limit Fat Limit Characteristic nutrition sources Low fat 1500 for women 1800 for men 30% Grains, vegetables, fruits, beans Mediterranean 35% Olive oil, nuts, vegetables, fish Low carbohydrate None 20 g/day of carbohydrate for 2 months, then 120 g/day of carbohydrates Fat, protein, and vegetables Shai I, et al. N Engl J Med. 2008;359:

16 Effect of Low-Fat, Low-Carbohydrate, and Mediterranean Diets on WeightDietary Intervention Randomized Control Trial (DIRECT) (N=322 Adults with Obesity) Weight Change Over 2 Years Adherence Over 2 Years Patients (%) Low fat Mediterranean Low carbohydrate Shai I, et al. N Engl J Med. 2008;359:

17 Effects of Different Diets on Weight Over TimeDietary Intervention Randomized Control Trial (DIRECT) All participants, 2 years (n=322) Completers, 2 years (n=272) Completers, 6 years (n=259) Mean Weight Loss (kg) Patients (%) 6-Year Diet Adherence Stayed on original diet Switched diet Stopped diet Schwarzfuchs D, et al. N Engl J Med. 2012;367:

18 Effects of Different Diets on Glucose and Lipids Over TimeDietary Intervention Randomized Control Trial (DIRECT) Effect on FPG at 2 Years Effect on Lipids at 2 and 6 Years No diabetes (n=286) T2D (n=36) Mean FPG (mg/dL) * *P<0.001 vs other diets. FPG = fasting plasma glucose; HDL = high density lipoprotein; LDL = low density lipoprotein; T2D = type 2 diabetes. Shai I, et al. N Engl J Med. 2008;359: Schwarzfuchs D, et al. N Engl J Med. 2012;367:

19 Effect of Mediterranean Diet Pattern on All-Cause Mortality12/19/2017 Effect of Mediterranean Diet Pattern on All-Cause Mortality NIH-AARP Diet and Health Study (n=214,284 men; n=166,012 women) Never Smokers Ever Smokers BMI (kg/m2) P value Men 18.5 to 25.0 0.02 25.0 to <30 <0.001 ≥30 0.51 Women 0.001 0.15 0.12 P value <0.001 0.002 Favors Mediterranean diet Favors Mediterranean diet AARP = American Association of Retired Persons; BMI = body mass index; NIH = National Institutes of Health Mitrou PN, et al. Arch Intern Med. 2007;167:

20 Lifestyle InterventionPhysical Activity

21 AACE Recommendations for Physical ActivityIndividualize recommendations according to patient goals and limitations Activities/exercise within capabilities and preferences Evaluate for contraindications and/or limitations to increased physical activity before beginning or intensifying an exercise program Set realistic goals and schedules Encourage increased nonexercise physical and leisure activity Taking stairs at work, weekend recreation Consider involvement of an exercise physiologist or certified fitness professional To individualize physical activity prescription To improve outcomes Garvey TW, et al. Endocr Pract. 2016;22(suppl 3):1-205.

22 AACE Recommendations for Aerobic and Resistance TrainingAerobic Training Resistance Training Goal ≥150 minutes/week* Greater moderate intensity (ie, “conversational”) physical activity (eg, brisk walking) Start slowly and build up gradually Additional 1-3% weight loss seen when higher intensity aerobic activity is added to a weight loss diet plan 2-3 sessions weekly* with major muscle groups Start slowly and build up gradually Results in improved body composition and metabolic risk factors Greater fat loss and less fat-free mass loss *Higher volume required for weight maintenance Garvey TW, et al. Endocr Pract. 2016;22(suppl 3):1-205.

23 How Much Physical Activity Is Enough?Randomized, Controlled, Community Based Study (N=278 Overweight Adults*) Physical activity (min/week) Reduced calorie diet + physical activity required for weight loss in studies with obese patients DPP (prediabetes): >150 min/week Look AHEAD (T2D): >175 min/week *BMI kg/m2. No reduction in energy intake. BMI = body mass index; DPP = Diabetes Prevention Program; T2D = type 2 diabetes. Jakicic JM, et al. Obesity (Silver Spring). 2011;19: DPP Research Group. N Engl J Med. 2002;346: Look AHEAD Research Group. Arch Intern Med. 2010;170:

24 Advice for Physical ActivityIntensity At least moderate, physical activity (conversational—should be able to talk comfortably) Heart rate ≥70% of maximum heart rate (max heart rate = 220 – age) Motivation Cross-train (ie, walk, ride, swim) Use a physical activity partner or professional trainer or attend organized programs Reward self Frequency ≥3-4 times/week Maintain a regular schedule with realistic goals) Support Health care professional team must exude positive attitude regarding importance of physical activity Handelsman Y, et al. Endocr Pract. 2015;21(suppl 1):1-87.

25 Advice for Physical ActivityHydrate Drink fluids (>18 ounces) 1-2 hours before exercise Stretch Include warm-up and cool-down periods of 5-10 minutes each Dress comfortably Wear silica gel or air midsoles and polyester seamless socks Be safe Check for blisters before and after activity Patients with T2D, neuropathy, or vascular disease Wear an ID bracelet if needed Have fun Aerobic and resistance training are both beneficial Be active with a friend

26 “But Doc, I Can’t Walk Too Far”All patients Low-impact activity: stationary bicycle, swimming, elliptical machine, stairstepper, treadmill, low-impact aerobics, weight-lifting machine Foot disease, peripheral vascular disease, arthritis Swimming, water aerobics, upper body resistance training Orthostatic conditions Semi-recumbent chair and weight lifting, semi-recumbent cycling, water exercise Elderly Stretching while sitting, elastic bands, movement exercise (eg, tai chi, hatha yoga) Any activity is better than no activity!

27 Effect of Physical Activity Type and Participation on Weight LossType of Physical Activity Level of Participation P<0.001† Weight (kg) Weight (kg) P<0.001‡ *≥150 min/week at 6 months but <150 min/week at 12 months. †All groups vs baseline; no group differed significantly from the others at 6 or 12 months.‡Group with ≥200 min exercise vs variable groups and group with <150 min of exercise. Jakicic JM, et al. JAMA. 2003;290:

28 Effect of Exercise Type on Body CompositionMRI Measured Change in Fat and Muscle Mass (N=136 men and women with abdominal obesity) * † * † Mean change in tissue mass (kg) * * * * * ‡ * ‡ *P<0.05 vs control. †P<0.05 vs aerobic exercise. ‡P<0.05 vs resistance training. SC = subcutaneous. Davidson LE, et al. Arch Intern Med. 2009;169:

29 Individual Variability in Body and Fat Mass ChangesIndividual Changes After 12 Weeks of Imposed Exercise (N=30 overweight or obese men and women) Change from baseline (kg) Patient King, NA, et al. Int J Obes (Lond). 2008;32:

30 Behavioral InterventionsLifestyle Intervention Behavioral Interventions

31 Lifestyle Intervention SupportIndividual Support Group Support Physician consultation and advice Rarely effective alone Dietitian consultation Must be repeated regularly Remote structured programs involving Internet and/or phone interactions Clinician-led weight loss support groups Commercial structured programs (eg, Weight Watchers, Jenny Craig) Physician-driven multidisciplinary team approaches (eg, DPP, EatRight) DPP = Diabetes Prevention Program.

32 Lifestyle Interventions Are Most Successful When SupportedExercise Behavioral therapy Hypocaloric nutrition Ongoing clinician follow-up Essential for maintenance of weight loss Essential for initial weight loss Structured programs (individual or group, in-person or telephone/Web-based) Physician advice and interest Regular consultation with dietitian

33 Intensive Lifestyle Interventions for ObesityDPP Trial Look AHEAD Trial ILI instruction in diet, exercise, and behavior change in patients with prediabetes First 6 months: ≥16 sessions >6 months: at least every other month individually or in group Low-fat diet: <25% of caloric intake; further calorie reduction if no weight loss DPP model ILI vs DSE in patients with T2D and CV risk Factors associated with weight loss maintenance Weight loss at year 1 Attendance at more treatment sessions Greater adherence to physical activity and energy intake recommendations 16% * Weight loss maintained after 4 years of follow-up Reduced risk of T2D with each kilogram of weight loss after 3.2 years of follow-up *P< vs DSE. CV = cardiovascular; DSE = diabetes support and education; ILI = intensive lifestyle intervention; T2D = type 2 diabetes. Hamman RF, et al. Diabetes Care. 2006;29: Wadden TA, et al. Obesity (Silver Spring). 2011;19(10):

34 The DEPLOY Pilot Study (N=92)DPP Model Community Intervention: Effect on Weight and Total Cholesterol The DEPLOY Pilot Study (N=92) P<0.001 P=0.008 P=0.002 P<0.001 4-6 months 12-14 months DEPLOY = Diabetes Education & Prevention with a Lifestyle Intervention Offered at the YMCA; DPP = Diabetes Prevention Program; YMCA = Young Men’s Christian Association. Ackermann RT, et al. Am J Prev Med. 2008;35:

35 DPP Model Community Interventions Foster AdherenceMontana Diabetes Control Program 16-session program based on DPP-style intervention (N=355) Week 100 99 98 97 96 95 94 93 92 91 90 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 350 300 250 200 150 50 Exercise per week (min) Mean weight (kg) Mean weight Physical activity 7% weight loss goal DPP = Diabetes Prevention Program. Amundson HA, et al. Diabetes Educ. 2009;35:

36 Effect of Commercial Portion-Controlled Meal PlanNutrisystem Trial in Patients with Type 2 Diabetes (N=69) DSME (n=34) Portion-controlled meal plan (n=35) DSME = diabetes self-management and education support. Foster GD, et al. Postgrad Med. 2009;121:

37 Benefits of Ongoing Behavioral SupportPractice Opportunities for Weight Reduction (POWER) Trial (N=415) No. patients 2 1 -1 -2 -3 -4 -5 -6 -7 -8 6 12 24  Weight (kg) Months Self-directed weight loss In-person support Telephone/Web-based support Appel LJ, et al. N Engl J Med. 2011;365:

38 Effects of Commercial Meal Replacement Plan With Ongoing SupportJenny Craig Trial (N=442)  Weight (%) P<0.001 Rock CL, et al. JAMA. 2010;304:

39 Effects of Commercial Meal Replacement Plan With Ongoing SupportWeight Watchers Trial (N=423)  Weight (%) P<0.001 P<0.001 Heshka S, et al. JAMA. 2003;289:

40 Practical Approaches to Lifestyle Interventions for Clinicians

41 Physician Discussion of Weight Status and Self-Reported Weight LossNHANES Respondents Reporting Weight Loss in Past Year Respondents (%) Overweight (n=2405) Obese (n=2649) NHANES = National Health and Nutrition Examination Survey. Pool AC, et al. Obes Res Clin Pract. 2014;8:e131-e139.

42 Set Realistic Goals With Your PatientGOAL: decrease risk of complications and improve long-term health Ask patient: What are your goals? Patients often want to lose ~30% of body weight A weight loss of “only” 7-10% may be deemed as “failure” by patients Advise patients to accept steady, incremental progress and emphasize that improved health—not necessarily reduced weight—is the goal Short-term weight loss goal (for most patients): 7% to 10% loss at 6 months Increase in muscle mass may be more important than decrease in fat mass Interim goal: weight maintenance Long-term goal (if desired): additional energy deficit recalculated for the next weight loss goal Remind patients that reducing caloric intake and increasing physical activity are key to achieving and maintaining weight

43 Lifestyle Therapy for Obesity: Features of Behavior ModificationOffice motivational interviewing Goal setting Self-monitoring Mobilization of social support systems Psychological counseling as needed Problem solving strategies Stimulus control Stress reduction Ongoing education and monitoring Face-to-face, group sessions, technologies Garvey TW, et al. Endocr Pract. 2016;22(suppl 3):1-205.

44 Motivational InterviewingDefinition Technique A guiding style of communication that helps Engage patients in self-care Clarify their strengths and aspirations Evokes their own motivations for change Promotes autonomy of decision making Ask Use open-ended questions to invite the patient to consider how and why they might change Listen Understand the patient’s experience Summarize with reflective listening Inform Ask permission to provide information Ask what the implications might be for the patient Rollnick S, et al. BMJ. 2010; 340:c1900. doi: /bmj.c1900.

45 Early Weight Loss Supports Long-Term SuccessWeight loss of >2.5% in the first month of the DPP predicted long-term weight loss success Stepped care approach involves education on problem solving skills and evaluation of outcomes Intensify behavioral lifestyle intervention if patients do not achieve a 2.5% weight loss in the first month Intervention and support should be tailored to each patient’s ethnic, cultural, and educational background DPP = Diabetes Prevention Program. Wing RR, et al. Obes Res. 2004;12:

46 Interview/Survey StudyImportance of Behavior Modification Support for Weight Loss Maintenance Interview/Survey Study (N=108 women) Escapes/ avoids problems (food/alcohol/drug use, excess sleep, wishful thinking) Confronts problems Seeks social support Actively reduces tension (extra work, recreation, relaxation techniques) Exercises regularly Respondents (%) Control = always at normal weight; maintainers = formerly >20% overweight but now normal weight; relapsers = currently >20% overweight and had previously lost and regained ≥20% of body weight. Kayman S, et al. Am J Clin Nutr. 1990;52:

47 Monitor Weight and Reinforce Weight Loss Goals During Follow-up VisitsMonitor and discuss weight status at each visit— open communication is vital Encourage self-monitoring of healthy eating and regular physical activity Remind patient of health benefits of maintaining a healthy weight Reinforce realistic short and long-term expectations Encourage continued adherence to healthy lifestyle and behavioral changes

48 Lifestyle Therapy in a Real World Setting: Number of Sessions and Weight LossSystematic Review and Meta-analysis* (N=28 studies of DPP translational model) Additional 0.26% weight loss with each additional lifestyle session attended r2 = 0.902; P<0.001 5 10 15 20 25 Number of sessions attended Number of sessions offered *Spearman Rank Correlation Test result. Blue line = best fit through the plot. DPP = Diabetes Prevention Program. Ali MK, et al. Health Aff (Millwood). 2012;31:67-75.

49 Effectiveness of Professional, Lay, and Online Counseling for Weight LossSystematic Review and Meta-analysis (N=28 studies of DPP translational model) Average Weight Loss by Program Leader/Type* Lay community member (n=5 studies) Clinician (n=19 studies) Electronic media (n=4 studies) Overall (N=28 studies) Weight change (%) (-5.46, -0.83) (-5.85, -2.70) (-7.62, -0.77) (-5.16, -2.83) *Pooled estimates of percentage weight change for each category of delivery personnel (95% confidence interval). DPP = Diabetes Prevention Program. Ali MK, et al. Health Aff (Millwood). 2012;31:67-75.

50 Recommended Components of SuccessA healthy, reduced calorie meal plan Dietitian visits Structured diets Commercial programs amd replacement meals Aerobic and resistance exercise Trainer, health coach, sports medicine Behavior change interventions Face-to-face office meetings Group sessions Remote technologies (telephone, internet, text messaging) Garvey TW, et al. Endocr Pract. 2016;22(suppl 3):1-205.

51 Lifestyle Therapy SummaryLifestyle interventions effectively prevent physical and metabolic complications of obesity Lifestyle alone is less effective in populations with higher stages of obesity Weight loss with lifestyle change is difficult to maintain Behavioral support may need to be intensified to assist with weight loss and maintenance Initial weight loss benefits are sustained even with weight regain Support groups Health care professional teams and community groups should help patients set realistic goals and encourage adherence to healthy weight loss/maintenance behaviors