Obesity Tip Sheet

I. Overview

Obesity is an epidemic in the United States. This condition puts people at a higher risk for serious diseases, such as type 2 diabetes, heart disease, and cancer.

According to the Centers for Disease Control and Prevention (CDC), it’s estimated that in 2015–2016, 93.3 million (39.8 percent) American adults and 13.7 million (18.5 percent) American children and teens are clinically obese.

Obesity is defined as having a body mass index (BMI) of 30 or more. BMI is a calculation that takes a person’s weight and height into account. However, BMI does have some limitations.

According to the CDC, “Factors such as age, sex, ethnicity, and muscle mass can influence the relationship between BMI and body fat. Also, BMI doesn’t distinguish between excess fat, muscle, or bone mass, nor does it provide any indication of the distribution of fat among individuals.” Despite these limitations, BMI continues to be widely used as an indicator of excess weight.

II. Weight Control Tips

1. Goal Setting

“It’s a dream, until you write it down and then it’s a goal.” Make SMART goals: Specific, Measurable, Achievable, Realistic/Relevant, and Time based. Mistakes made in setting goals: Too big, too many, too vague, and not written down.

2. Nutrition

Hedonic hunger is when a person’s eating behavior is motivated by the pleasure of food rather than hunger. This activates our reward system related with food, which can lead to overeating. A person can have an increased appetite due to the disruption of their reward pathways with dopamine receptor levels in the brain. This can happen purely through habit formation around food consumptions, but increased appetite can be due to a developed medical problem. Be sure to rule out any medical reasons for weight gain with the primary care provider (i.e. hypothyroidism).

As available, coordinating care with a nutritionist is recommended. In the meantime, training in mindful eating and education on healthy food choices are a good first step. Assessment of the patient’s struggles with food will be pivotal for the direction of treatment. Potential barriers:

access to healthy food, stress triggering emotional eating, affordability of healthy foods, and knowledge of nutrition.

3. Exercise and Physical Activity

Along with the change in food behavior, successful weight loss is dependent on exercise and leaving behind a sedentary lifestyle. Exercise and physical activity can also help with symptoms of depression and anxiety. The recommended standard is 30 minutes of moderate intensity exercise 5 out of 7 days. This amount of exercise is associated with a significant decrease in chronic disease.

If a person is experiencing ambivalence in their abilities to exercise, they may experience low self-efficacy (confidence in one’s ability) for exercising. This can be assessed (refer to exercise: self efficacy survey) and used to recognize this as a barrier.

4. Health Behavior Change

Most who suffer from weight gain wish they could fix it by taking a pill, but more often than not simply taking a pill will not solve a person’s weight problems. Most research identifies lifestyle changes such as moving from a sedentary routine to an active routine and consumption of processed high calorie foods to healthy foods full of nutrients, as most effective. Changes in diet and exercise are new habits that are difficult to develop. The Transtheoretical Stages of Change model and Motivational Interviewing skills are useful with the challenge of health behavior change.

5. Social Support

It is vital for weight control and life style behavior changes. It may be important to help the patient try and get buy-in on the healthy behavior change with a spouse, family members, or finding a formal social support group (i.e. Weight Watchers).

III. Weight Management

Effective weight management involves behavior modification, which is a lifelong commitment and includes at least two components:

1. Healthy eating in accordance with the Dietary Guidelines for Americans, emphasizing a reduction in total calories, lowered fat consumption, and an increase in vegetables, fruits and whole grains.

2. Increased frequency of regular physical activity of at least moderate intensity.

1. Eating Healthy

Caloric intakeLosing weight requires burning more calories than the body takes in, by either reducing caloric intake or increasing caloric expenditure, or preferably, both.

Estimated Calorie Requirements (in Kilocalories) for Each Gender and Age Group at Three Levels of Physical Activity

Activity Level b, c, d

Gender Age (years) Sedentaryb Moderately Activec Actived

Child 2-3 1,000 1,000-1,400 1,000-1,400Female 4-8 1,200 1,400-1,600 1,400-1,800

9-13 1,600 1,600-2,000 1,800-2,20014-18 1,800 2,000 2,40019-30 2,000 2,000-2,200 2,40031-50 1,800 2,000 2,200

51+ 1,600 1,800 2,000-2,200Male 4-8 1,400 1,400-1,600 1,600-2,000

9-13 1,800 1,800-2,200 2,000-2,60014-18 2,200 2,400-2,800 2,800-3,20019-30 2,400 2,600-2,800 3,00031-50 2,200 2,400-2,600 2,800-3,000

51+ 2,000 2,200-2,400 2,400-2,800Source: HHS/USDA Dietary Guidelines for Americans, 2005

Sedentary = less than 30 minutes a day of moderate physical activity in addition to daily activities.

Moderately Active = at least 30 minutes up to 60 minutes a day of moderate physical activity in addition to daily activities.

Active = 60 or more minutes a day of moderate physical activity in addition to daily activities.

Healthy Food ChoicesIndividualized food plan according to 2005 USDA Dietary Guidelines: http://www.mypyramid.gov/mypyramid/index.aspx

Four key recommendations of the 2005 Dietary Guidelines for food groups to encourage are:

1. Consume a sufficient amount of fruits and vegetables while staying within energy needs. Two cups of fruit and 2-1/2 cups of vegetables per day are recommended for a reference 2,000-calorie intake, with higher or lower amounts depending on the calorie level.

2. Choose a variety of fruits and vegetables each day. Eat fresh, frozen, canned, or dried fruit, rather than drinking fruit juice, for most of your fruit choices.

Select from all five vegetable subgroups several times a week. Examples of vegetables from these subgroups include:

• DARK GREEN VEGETABLES -- Broccoli, spinach, most greens such as spinach, collards, turnip greens, kale, beet and mustard greens, green leaf lettuce, and romaine lettuce

• ORANGE VEGETABLES -- Carrots, sweet potatoes, winter squash, pumpkin

• LEGUMES (DRY BEANS) -- Dry beans, chickpeas

• STARCHY VEGETABLES -- Corn, white potatoes, green peas

• OTHER VEGETABLES -- Tomatoes, cabbage, celery, cucumber, lettuce, onions, peppers, green beans, cauliflower, mushrooms, summer squash

3. Consume 3 or more one-ounce equivalents of whole-grain products per day, with the rest of the recommended grains coming from enriched or whole-grain products. In general, at least half the grains should come from whole grains. Examples of whole-grains commonly consumed in the United States include:

• whole wheat • whole rye • bulgur (cracked wheat) • brown rice• whole oats/oatmeal • whole-grain barley • millet • tritacale• whole-grain corn • wild rice • quinoa

4. Consume 3 cups per day of fat-free or low-fat milk or equivalent milk products. If you don't or can't consume milk, choose lactose-free milk products and/or calcium-fortified foods and beverages.

For more information, visit: http://lancaster.unl.edu/food/ftfeb05.htm.

Food log By keeping track of food and drink consumption you will stay mindful of your eating habits. Do you eat when bored? Do you eat unhealthy foods when in a hurry? Are you eating something that seems nutritious and healthy, but really isn’t? You can calculate calories consumed to determine weight loss/maintenance goals and assess progress. Keeping a food log allows you to be accountable and mindful of calories consumed and you will become aware of the nutrient value of the foods/drinks you are using.

An on-line calorie counter is available at http://www.my-calorie-counter.com. This site lets you count calories for free (extra features cost $35/year).

Portion SizeAnother common problem leading to overeating is taking portions that are too big. Most of us overestimate the size of a healthy portion, especially when we eat at restaurants and want to get a “good value” for our money. Listed below are the recommended portion sizes for a variety of foods. How do your typical portions compare?

3 oz. meat: size of a deck of cards or bar of soap (the recommended portion for a meal)• 8 oz. meat: size of a thin paperback book

• 3 oz. fish: size of a checkbook

• 1 oz. cheese: size of 4 dice

• Medium potato: size of a computer mouse

• 1/2 cup pasta: size of a tennis ball

• Average bagel: size of a hockey puck.

• 1 cup chopped raw vegetables or fruit: baseball size

• 1/4 cup dried fruit (raisins, apricots, mango): a small handful

For more information, visit http://www.cancer.org/docroot/PED/content/PED_3_2x_Portion_Control.asp

2. ExerciseExercise is an important piece of weight loss and overall health. For example, 30 minutes of moderate intensity physical activity above your normal daily routine reduces the risk of chronic disease in adulthood. To manage body weight and prevent gradual, unhealthy body weight gain in adulthood, increase your exercise to approximately 60 minutes of moderate to vigorous intensity activity on most days of the week. To sustain weight loss, increase your exercise to 60 - 90 minutes per day of moderate intensity physical activity while not exceeding caloric intake requirements.

Another way to track physical activity is to use a pedometer to keep track of the number of steps you take. For example, 2000-2500 average steps is approximately one mile, which equates to around 100 expended calories.

3. Simple Strategies to Manage Your Eating How often have you over-eaten or eaten unhealthy foods due to eating effortlessly in an unaware and mindless manner? Have you ever noticed that when you’re done eating, you feel sick because you ate too much? This happens when we do not pay attention to eating, typically because we are doing something else at the same time like watching television, talking with others, or working. If you increase your awareness—or mindfulness—of eating, however, you can reduce your caloric intake and not feel so sick. Mindfulness is a way of observing your

experiences and being in touch with your actions, thoughts and feelings. Mindful eating teaches you to pay attention to your bodies’ signals that you are full and about what foods to eat. The goal of mindful eating is to understand your hunger and your body and mind’s reaction to food and the process of eating. Try this activity:

Mindful eatingTo start, move through the meal slowly. Take your time performing every action and notice what your experience is as you go through it. When you lift a fork or cut your meat, note what that is like for you. As you place a bite of food in your mouth and chew it, place your fork on the table and think about the flavors and the texture of the food. Is it enjoyable or repulsive? Don’t get hung up in judging it. Just notice it. Do you find that particular thoughts or feelings come up during the course of the meal? If so, simply note those as well.

For more information about mindful eating consider reading these books: 1. Albers, S. (2003). Eating Mindfully. Oakland: New Harbinger Publications, Inc.

2. Hayes, S.C. (2005). Get Out of Your Mind and Into Your Life. Oakland: New Harbinger Publications.

4. Developing Weight GoalsSetting SMART goals for your weight loss is the first, and most important, step for managing your weight. Good goals have several qualities:• Specific: Goals should not be too general or vague, since this makes it hard for us to

know when we have accomplished them. For example, “I want to lose 20 pounds” is a better goal than “I want to lose weight.”

• Measurable: Goals should be set in a way that can easily and meaningfully measured. For example, “I want to look better” is not easily measured, but “I want a 34-inch waist” is easily measured.

• Attainable: Goals should be something you are motivated to achieve. For example, if improving your PT score is more important to you than your overall weight, then your goal should not be to lose weight.

• Realistic: Goals should be something you are able to accomplish. For example, setting a goal to run a marathon next month when you struggle to run 2 miles now is not a realistic goal.

• Timely: Goals should have a time frame built into them to hold you accountable. You’re more likely to work towards a goal if you give yourself a deadline.

Body Mass Index (BMI) & Waist SizeBMI uses a mathematical formula that takes into account both a person's height and weight. BMI equals a person's weight in kilograms divided by height in meters squared. (BMI=kg/m2). It is

the measurement of choice for many physicians and researchers studying obesity, because it is a more accurate indicator of overall health than just weight alone. Setting a BMI goal, instead of simply a weight loss goal, is a better weight management strategy for many people, especially those with medical conditions such as diabetes, COPD, heart diseases, hypertension, and more. To calculate your BMI, visit this website: http://www.consumer.gov/weightloss/bmi.htm.

Risk of Associated Disease According to BMI and Waist Size

BMIWaist less than or equal to40 in. (men) or35 in. (women)

Waist greater than40 in. (men) or35 in. (women)

18.5 or less Underweight -- N/A

18.5 - 24.9 Normal -- N/A

25.0 - 29.9 Overweight Increased High

30.0 - 34.9 Obese High Very High

35.0 - 39.9 Obese Very High Very High

40 or greater Extremely Obese Extremely High Extremely High

Setting a SMART Weight Management GoalSpecific:Where will you do it?With whom will you do it?How often will you do it?Measureable:How much?How many?Attainable:What is most important to you?What do you hope to accomplish?Realistic:Are you able to do it?What can you do right now?How easy will this be to maintain?Timely:When do you want to accomplish this?Do you have a deadline?

Now that you have considered the necessary components for a SMART goal, write down your weight management goal below:

Other tips for accomplishing this goal:

1. Hang this goal up where you can see it regularly so you can remind yourself what you’re working towards.

2. Tell others about it. Ask them to help you stay accountable and support you.

3. Ask your doctor for advice or tips on reaching this goal.

4. Try this goal out for two weeks. At the end of two weeks, see if it’s a goal that will work for you. If not, change it so it will work better.

5. Once you have accomplished this goal, set another SMART goal right away.

6. Remember to pace yourself. Change will not happen all at once, but will slowly build up over time. Be patient.

Exercise and Physical ActivityMost people have been told, “you need to exercise more” or “If you did some sort of physical activity, you would probably feel better”? Exercise and physical activity of any kind is healthy and can help increase positive mood and energy. It can also decrease weight, stress and blood pressure, increase alertness and motivation to accomplish other goals. This isn’t earth shattering news, as a matter of fact it is hard to find anyone who hasn’t heard these things before. Yet, it still isn’t enough to get people up and moving. So, if most people already know that physical activity and exercise have so many positive attributes, why is it that so many people don’t engage in these activities? (especially when experiencing anxiety, depression or significant life stress)

When people feel down or depressed, stressed or nervous they tend to cut out healthy activities that normally bring value, meaning and enjoyment to their lives. Giving up healthy habits in the face of negative mood and life stress seems to be the path of least resistance for most, and the initiation of a cycle that is difficult to stop.

Finding reasons not to exercise isn’t difficult, where most people get “stuck” is in problem solving and finding ways to overcome barriers to change. Sometimes, being able to weigh the reasons NOT to exercise against the reasons to DO exercise can help create the motivation and rationale to begin MOVING forward. Try using the scale below to “weigh” your options……

REASONS TO EXERCISE• Improve mood• Increase Energy• Weight Control• Improve Sleep• Stress Reduction• Lower Blood Pressure• Lower Cholesterol• Increase Muscle Tone• Decrease Chronic Pain• Improve Concentration• Increase Metabolism• Improve Cardiovascular

functioning• Enhance Stamina for Daily

REASONS NOT TO EXERCISE• Feeling Sad • Feeling Sick• Low Energy • No Social Support• Exercise Goal is

Unattainable• Don’t Have Proper

Attire• Too Busy • Too Tired• Too Hot or Cold • Pain• Low Level of

Interest• Intimidated by Gym

People

List Top 3 Reasons to Exercise

1.

2.

3.

• My short term exercise goal is: ______________________________________________

• My long term exercise goal is: ______________________________________________

• When I REALLY don’t feel like exercising I will: __________________________________

• I will look to: ________________________________for support in my effort to exercise.

• I will reward myself with: __________________________________________________

*Post this list in a place where you will see it several times each day!

GETTING STARTED

• Check with your doctor - It is always a good idea to check in with your doctor before beginning a new fitness program. This is particularly true if you're over 40, if you smoke, or if you have a family history of cardiovascular disease, high blood pressure, elevated cholesterol, diabetes, arthritis, or asthma.

• Have fun - Choose an activity you like or want to do. You're much more likely to stick with it. If you find your first choice doesn't suit you, switch to something else.

• Start slowly and progress gradually - You'll avoid becoming discouraged and reduce the risk of injury.

• Set goals - Maybe you want to lose a little weight, get in shape for a particular sport you enjoy, or reduce arthritis pain and increase joint mobility.

• Keep track - You may not notice that you're walking further in the same amount of time or that you're not as winded climbing the stairs. Keeping track helps you evaluate your progress and gives you a sense of accomplishment.

• Reward yourself - When you reach a goal, buy yourself a new T-shirt or tennis racket.

• Find a partner - It's more fun to share and you'll keep each other on track.

• Have a plan B - If it's raining, walk around an indoor mall or do an exercise video.

• Include variety - You're less likely to become bored if you cross train. Include the three basic forms of exercise in your fitness program: aerobics, strength training, and stretching. Or if you prefer, alternate your activities, basketball one day, yoga another, and stacking wood on the third. The thing to remember is that ANY activity will help you burn calories!

• Stick with it - You have to exercise regularly for your fitness to improve. Fifteen to thirty minutes a day is all that is required to see improvement and you'll enjoy the same benefits if you find it easier to fit two 15 minute or two to three 10 minute sessions into your day.

Daily Exercise

GoalDate Type of

Activity

Level of Difficulty Low-Mod-

Diff

Total Exercise

Time

Reward for Completion of

Goal

IV. Screeners

Screening for obesity has been routinely measured through Body Mass Index (BMI). Though common, has been argued as a poor measure to determine someone’s health status in term of needing to lose “weight.” BMI measures the ratio between pure weight and height without consideration of body composition, which consists of both lean body mass and body fat. Lean body mass is bone, muscle, ligaments, tendons, organs, and everything else that is not fat. Body fat is purely adipose tissue, which is of primary concern for the effects of obesity on cardiovascular health. For the majority of the population BMI is a reliable measure to predict health risks for populations, but is no longer reliable for prediction of individual health.

Seven-sight skin fold test (SSSFT) is a potential measure of progress in treatment as a better indicator for fat loss. SSSFT can be both a reliable screener for obesity and a test for progress in treatment success. The problem is that it takes skill to become consistent with the measurements. Adequate direction and practice can provide consistency that makes the SSSFT a better choice in testing program progression. Using a tape measure to take measurements of various parts of the body may also be a tangible option for progression.

Waist-to-hip ratio has been significantly linked with health hazards and can be applied to both men and women. It may be a more accurate predictor of mortality than BMI. To measure the patient’s waist-to-hip ratio you measure at the slimmest point on their waist and the hips at the widest point, then divide the waist measurement by the hip measurement. As a rule, the desirable waist-to-hip ratio is less than 0.8 for women and less than 0.95 for men.

Additional measures of interest may be blood pressure, cholesterol, and heart rate, all of which show a positive correlation with body fat percentage. Whatever the measurement for monitoring progress, the individual must be considered when deciding the approach. Excessive monitoring at times has been shown to be harmful for progress. The monitoring can discourage or become an obsession that contributes to problems with control.

Progress Tracking Use of fitness watches, phone applications, or spreadsheets.

http://www.choosemyplate.gov/ten-tips

Choose My Plate is a great resource for information on nutrition and exercise information.

SuperTracker, under online tools, can help plan organize and track diet and physical activity.

Exercise: Self-Efficacy

This part looks at how confident you are to exercise when other things get in the way. Read the following items enter in the box the number that best expresses how each item relates to you in your leisure time. Please answer using the following 5-point scale:

1 = Not at all confident2 = Somewhat confident3 = Moderately confident4 = Very confident5 = Completely confident

Subscale and items  (Alpha)

Negative Affect (.852)I am under a lot of stress.**

I am depressed.

I am anxious.

Excuse Making (.829)I feel I don’t have the time.**

I don’t feel like it.

I am busy.

Must Exercise Alone (.869)

I am alone.

I have to exercise alone.**

My exercise partner decides not to exercise that day.

Inconvenient to Exercise (.773)

I don’t have access to exercise equipment.**

I am traveling.

My gym is closed.

Resistance from Others (.853)

My friends don’t want me to exercise.

My significant other does not want me to exercise.

I am spending time with friends or family who do not exercise.**

Bad Weather (.837)

It’s raining or snowing.**

It’s cold outside.

The roads or sidewalks are snowy.

Note: ** Items to be used for six-item self-efficacy short assessment. (If possible we recommend using the 18-item version). 

Resources

Aamodt, S. (2013, June). Why dieting doesn’t usually work [video file]. Retrieved from: https://www.ted.com/talks/sandra_aamodt_why_dieting_doesn_t_usually_work

Benisovich, S.V., Rossi, J.S., Norman, G.J., and Nigg, C.R. (March, 1998). A multidimensional approach to exercise self-efficacy: Relationship with exercise behavior and attitudes towards exercise. Paper presented at the annual meeting of the New England Psychological Association, Boston, MA.

Benisovich, S.V., Rossi, J.S., Norman, G.J. & Nigg, C.R. (March, 1998). Development of a multidimensional measure of exercise self-efficacy. Poster presented at the Society of Behavioral Medicine (SBM). New Orleans, LA.

Marcus, B.H., Selby, V.C., Niaura, R.S., & Rossi, J.S. (1992). Self-efficacy and the stages of exercise behavior change. Research Quarterly for Exercise and Sport, 63, 60-66.

Orzano A. J. & Scott J.G. (2004). Diagnosis and treatment of obesity in adults: an applied evidence-based review. Journal of the american board of family medicine. Doi: 3122/jabfm.17.5.359

“Talking with patients about weight loss in primary care.” National Institute of Health.

Retrieved from http://www.niddk.nih.gov/health-information/health-topics/weight-

control/talking-with-patients-about-weight-loss-tips-for-primary-care/Pages/

talking.aspx#j

“What is obesity?” Healthline. Retrieved from https://www.healthline.com/health/obesity

Wishon, P. M. (1989). Adolescent Obesity. International Journal of Adolescence and Youth, 2(1), 43-51.

Wrotniak, B. H., Epstein, L. H., Paluch, R. A., & Roemmich, J. N. (2004). Parent weight change as a predictor of child weight change in family-based behavioral obesity treatment. Archives of pediatrics & adolescent medicine,158(4), 342-347.