Weight Management

Weight management has been thought of as only weight loss by many. Weight management covers all aspects of attaining and maintaining optimum weight for a healthy lifestyle. Health professionals now realize that prevention of weight gain as well as weight loss and improving health status are important goals. These goals must be individualized for success.
At the outset of treatment, the patient and health care provider should discuss and agree upon goals. The goals must take into account the food habits, exercise behaviors, psychological outlook and support systems of the individual. Realistic expectations, short- and long-term, may be promoted by a discussion of a healthy weight versus an ideal body weight. Features of weight management interventions may include behavior modification, dietary principles, energy balance components, and a sound food plan.
In order to create a behavior modification plan that will be successful for the individual, identifying cues, responses and consequences of eating behaviors is necessary. Control of eating behavior, physical activity, emotional, social, and psychological health must all be analyzed and interventions applied. Behaviors related to problems with intake and expenditure of energy must be specifically defined. Recording and analyzing eating and exercise behaviors to develop strategies aimed at learning new behaviors are essential.
Dietetic practice in weight management is complex and challenging. Assessment of weight and health should guide weight management goals and outcomes. The weight and dieting history should include age of onset of weight problems, number and types of diets, exercise history, possible triggers to weight gains and losses, and an appropriate range of weight change. The Body Mass Index (BMI) is considered the standard measurement for weight status. The BMI is estimated by weight (kg) divided by height (m2). A BMI of 25 – 29 is considered overweight and some weight loss is recommended. There is debate surrounding how much weight loss should be attained.
In considering a weight management plan, it is necessary to incorporate each of the following:
• realistic goals (weight loss average of ½ to 1 pound per week);
• energy intake limits related to the energy output of the individual (the Basal Metabolic Rate (BMR) + activity level should be used to determine range of intake (see Table 1));
• a nutritionally adequate diet; (A balance of carbohydrates, fats, and proteins with variety and appealing foods is needed for successful weight management. Foods should be similar to those individual is used to eating to encourage permanent behavior changes.) and
• energy intake adjustments when the weight goal is reached in order to maintain optimal weight.
A negative energy balance is the goal for weight loss. For weight loss, the BMR, caloric intake, and caloric expenditure are analyzed. It is necessary to determine the kilocalorie adjustment needed for weight loss (see Table 2). For proper energy balance during weight reduction ½ of the reduction should come from a reduction in caloric intake, and ½ should be derived from increased physical activity. A neutral energy balance must be met for weight maintenance.
It is advisable to create a general guide for weight maintenance. When developing a food plan, the nutrient balance should consist of 45 – 65% carbohydrates, 10 -35% proteins, and less than or equal to 25% fats. The distribution balance is also a key aspect to weight management. The distribution balance requires caloric intake spread throughout the day. Identifying problem times and planning healthy snacks for these times is necessary to maintain distribution balance.
A food guide (a reference for comparative food values and portions) can help the individual with weight management, whether for loss, gain or maintenance. This guide will help identify a variety of healthy food choices, and assist with meal planning while the individual learns new food behaviors.
It is well established that physical activity during weight loss can favorably affect energy balance and body composition. Physical activity has been shown to aid in the preservation of lean body mass during weight loss. The addition of moderate physical activity to the restriction of energy intake has been shown to limit the loss of lean body mass to less than 10%. Physical activity may positively influence the distribution of body fat independent of its effect on body weight. Clearly, preventing regain of fat losses (or maintaining weight gain in the underweight) is the major challenge of weight maintenance. Regardless of the effects exercise has on weight management, there is strong evidence that increased physical activity increases cardio-respiratory fitness with or without weight loss.
It is not established that these behaviors represent what is minimally necessary for weight loss maintenance. However, these proposed lifestyle modifications on an ongoing basis have produced long-term weight maintenance and health benefits outside weight management.
Severe energy restricted diets, such as very low calorie diets, may provide short-term success in achieving significant weight losses; however, there is poor long-term maintenance of losses. Patients often are attracted to diets and programs that promise magical, no-stress weight loss. These "magic" diets do not promote healthy lifestyle changes.
As stated earlier, achieving and maintaining healthy lifestyle behaviors, including activity and food intake, can help weight management. Health can be improved with relatively minor weight losses or gains. A weight loss of 10% may ameliorate health risks associated with excessive body weight. A weight gain of 10 – 20% in the underweight may ameliorate health risks associated with too little body weight. A challenge to health care providers is helping individuals to accept a 10% weight change (loss or gain). By creating the guide above, and implementing the steps necessary to incorporate the changes, a health care provider enables the individual to reach and maintain his or her goal. Table 1
Daily Energy Needs (basis for calculations) Activity energy needs above basal (%) Male
(70 kg) kcal Female
(58 kg) kcal
Basal energy needs 1 kcal/kg per hour 70 kg x 24 hours = 1680 58 kg x 24 hours = 1392
Activity energy needs Sedentary + 20% basal 1680 + 336 = 2016 1392 + 278 = 1670 Very light + 30% basal 1680 + 504 = 2184 1392 + 418 = 1810 Moderate + 40% basal 1680 + 672 = 2352 1392 + 557 = 1949 Heavy + 50% basal 1680 + 840 = 2520 1392 + 696 = 2088
From Basic Nutrition & Diet Therapy, 12th edition. Stacy Nix, 2005, page 2
Table 2
Kilocalorie Adjustment Necessary for Weight Loss
To lose 454 g (1 lb) per week = 500 fewer kcal daily
Basis of Estimation:
1 lb body fat = 454 g
1 g pure fat = 9 kcal
1 g body fat = 7.7 kcal (some water in fat cells)
454 g x 9 kcal/g = 4086 kcal/454 g fat (pure fat)
454 g x 7.7 kcal/g = 3496 kcals/454 g body fat (or 3500 kcals)
500 kcal x 7 days = 3500 kcals = 454 g body fat
From Basic Nutrition & Diet Therapy, 12th edition. Stacy Nix, 2005, page 2

References
1. Hill JO, Peters JC. Environmental contributions to the obesity epidemic. Science. 1998;280:1371-1374.
2. Willett WC, Dietz WH, Colditz GA. Primary Care: Guidelines for healthy weight. New England Journal of Medicine. 1999;341:427-434.
3. National Task Force on the Prevention and Treatment of Obesity, National Institutes of Health. Very low-calorie diets. Journal of the American Medical Association. 1993;270:967-974.
4. Stein K. High-protein, low carbohydrate diets: Do they work? Journal of the American Dietetic Association. 2000,100:760-761.
5. Jeffery RW, Drewnowski A, Epstein LH, Stunkard AJ, Wilson GT, Wing RR, Hill DR. Long-term maintenance of weight loss: current status. Health Psychology. 2000;1(Suppl):5-16.
6. Byfield C. A lifestyle physical activity intervention for obese sedentary women: Effect on cardiovascular disease risk factors. American College of Sports Med: Indianapolis IN; 2000.
7. Rosen JC. Improving body image in obesity. In: Thompson, JK, ed. Body Image, Eating Disorders and Obesity. Washington, DC: American Psychological Association; 1996: 425-550.
8. Nix S. Basic Nutrition & Diet Therapy, 12th edition. 2005: 268-287.
9. Martini F. Fundamentals of Anatomy & Physiology, 6th edition. 2004: 928-964.

References: 1. Hill JO, Peters JC. Environmental contributions to the obesity epidemic. Science. 1998;280:1371-1374. 2. Willett WC, Dietz WH, Colditz GA. Primary Care: Guidelines for healthy weight. New England Journal of Medicine. 1999;341:427-434. 3. National Task Force on the Prevention and Treatment of Obesity, National Institutes of Health. Very low-calorie diets. Journal of the American Medical Association. 1993;270:967-974. 4. Stein K. High-protein, low carbohydrate diets: Do they work? Journal of the American Dietetic Association. 2000,100:760-761. 5. Jeffery RW, Drewnowski A, Epstein LH, Stunkard AJ, Wilson GT, Wing RR, Hill DR. Long-term maintenance of weight loss: current status. Health Psychology. 2000;1(Suppl):5-16. 6. Byfield C. A lifestyle physical activity intervention for obese sedentary women: Effect on cardiovascular disease risk factors. American College of Sports Med: Indianapolis IN; 2000. 7. Rosen JC. Improving body image in obesity. In: Thompson, JK, ed. Body Image, Eating Disorders and Obesity. Washington, DC: American Psychological Association; 1996: 425-550. 8. Nix S. Basic Nutrition & Diet Therapy, 12th edition. 2005: 268-287. 9. Martini F. Fundamentals of Anatomy & Physiology, 6th edition. 2004: 928-964.