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Overcoming Obesity and a Sedentary Lifestyle In Terms They Can Understand

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Only 34 percent of adults who had seen a physician in the prior year reported being counseled about physical activity at their last physician visit. The average American makes three office visits per year, and 60 percent of office visits are made to primary care physicians. Research has shown that those patients who received advice to lose weight were significantly more likely to try losing weight than those who did not receive such advice. AFP Journal – May 2004

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Physician Barriers to Evaluation and Treatment of Obesity Lack of payment by most health-insurance and managed-care plans for obesity-related treatment programs Lack of time for dedicated patient education and counseling on weight loss and weight maintenance Lack of recognition of obesity as a chronic condition that is difficult to treat, requires continuous and long-term management, and has high recidivism rates Lack of patient interest or readiness for treatment Negative and unsympathetic perceptions that obesity represents a lack of patient discipline, self-control or will power rather than a chronic disease Inadequate training and lack of training mechanisms for physicians in the medical management of obesity AFP Journal - June 2001

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“Sudden death is more common in those who are naturally fat than in the lean.” - Hippocrates Chadwick J, Mann WN. Medical works of Hippocrates

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What We Know About Obesity-Related Morbidity People who are obese have higher rates of: Hypertension Dyslipidemia Type II diabetes Coronary heart disease Stroke Gallbladder disease Osteoarthritis Sleep apnea and respiratory problems Some cancers (endometrial, breast, colon)

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Risk Factors for Heart Disease (Ages 20 and over) 1999-2002 Hypertension or taking hypertension medications (30.2%) High blood cholesterol (17.3%) Diabetes (6.5%) Current cigarette smokers (21.6% - 2003) No leisure-time physical activity (37.6% - 2003) Obese (30.5%) www.CDC.gov

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What They Should Know About Their Obesity They have a higher chance of: Heart attacks and heart failure Blindness Stroke Needing dialysis Amputations Chronic back and joint pain Erectile Dysfunction Cancer

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How Do We Define Obesity? BMI BMI = Weight (kg) / Height (m2) 25 – 29.9 = overweight >30 = obese

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What Does BMI Mean to Them ?

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So How Should We Use BMI? Identify those at risk Projecting a target or ideal weight (calculate weight needed for BMI of 25 or less)

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What We Tell Them About Weight Management Diet Exercise

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Recommendations for Adult Weight Loss Therapy Initially, attempt to reduce body weight by approximately 10 percent from baseline. With success, attempt further weight loss, if indicated, through further assessment. Reduce weight at a rate of about 1 to 2 lb per week for six months. Base subsequent strategies on the amount of weight lost. Goals: Adapted from National Institutes of Health, National Heart, Lung, and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults--the evidence report. Obesity Res 1998;6(suppl 2):51S-209S

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Recommendations for Adult Weight Loss Therapy Encourage low-calorie diets for overweight and obese adults. As part of a low-calorie diet, fat reduction is a practical way to reduce calories. Reducing dietary fat alone without reducing total calories is not sufficient for weight loss. Dietary Therapy: Adapted from National Institutes of Health, National Heart, Lung, and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults--the evidence report. Obesity Res 1998;6(suppl 2):51S-209S Reducing dietary fat along with dietary carbohydrates facilitates caloric reduction. An individually planned diet creating a deficit of 500 to 1,000 kcal per day should be an integral part of any program aimed at achieving a weight loss of 1 to 2 lb per week.

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Recommendations for Adult Weight Loss Therapy Exercise contributes modestly to weight loss in overweight and obese adults. Physical activity may decrease abdominal fat. Physical activity increases cardiorespiratory fitness. Physical Activity: Adapted from National Institutes of Health, National Heart, Lung, and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults--the evidence report. Obesity Res 1998;6(suppl 2):51S-209S Physical activity should be an integral part of weight loss therapy and weight maintenance. Initially, encourage moderate levels of activity for 30 to 40 minutes per day, three to five days per week. Set a long-term goal to accumulate at least 30 minutes or more of moderate-intensity physical activity on most, preferably all, days of the week.

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Popular Weight-Loss Diets Atkins NutriSystem South Beach Sonoma 5 Factor Jenny Craig Weight Watchers These diet plans do have their merits and success stories (Weight Watchers has been around for over 40 years). However, for most of our patients, these diets are impractical, expensive and too complex. A common theme in most successful diets is portion control and limited calories.

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What They Should Know About Weight Management Their weight is a balancing act between the energy they eat and the energy they use every day. That energy is measured in calories. Weight Gain Weight Loss Someone who is maintaining a consistent weight is, on average, consuming the same number of calories as their body uses daily and has achieved a “calorie balance”. www.CDC.gov

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Estimated amounts of calories needed to maintain energy balance for various gender and age groups at three different levels of physical activity. (a) Activity Level Gender Age (yrs) Sedentary (b) Moderately Active (c) Active (d) Child 2-3 1,000 1,000-1,400 1,000-1,400 Female 4-8 9-13 14-18 19-30 31-50 51+ 1,200 1,600 1,800 2,000 1,800 1,600 1,400-1,600 1,600-2,000 2,000 2,000-2,200 2,000 1,800 1,400-1,800 1,800-2,200 2,400 2,400 2,200 2,000-2,200 Male 4-8 9-13 14-18 19-30 31-50 51+ 1,400 1,800 2,200 2,400 2,200 2,000 1,400-1,600 1,800-2,200 2,400-2,800 2,600-2,800 2,400-2,600 2,200-2,400 1,600-2,000 2,000-2,600 2,800-3,200 3,000 2,800-3,000 2,400-2,800 a These levels are based on Estimated Energy Requirements (EER) from the Institute of Medicine Dietary Reference Intakes macronutrients report, 2002, calculated by gender, age, and activity level for reference-sized individuals. "Reference size," as determined by IOM, is based on median height and weight for ages up to age 18 years of age and median height and weight for that height to give a BMI of 21.5 for adult females and 22.5 for adult males. b Sedentary means a lifestyle that includes only the light physical activity associated with typical day-to-day life. c Moderately active means a lifestyle that includes physical activity equivalent to walking about 1.5 to 3 miles per day at 3 to 4 miles per hour, in addition to the light physical activity associated with typical day-to-day life d Active means a lifestyle that includes physical activity equivalent to walking more than 3 miles per day at 3 to 4 miles per hour, in addition to the light physical activity associated with typical day-to-day life. Dietary Guidelines for Americans, 2005 U.S. Department of Health and Human Services

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How Do Calories Translate Into Their Weight Loss/Gain? There are approximately 3,500 calories (actually kcal) in one pound of stored fat. For every 3,500 calories excess eaten, one pound is gained. For every 3,500 calories deficit , one pound is lost. A goal of one pound per week weight loss is not only reasonable, it makes good math. 3,500 calories / 7 days = 500 calorie daily deficit

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How to Achieve a 500 Calorie/Day Deficit Reduced calorie foods Dietary Modifications Reduced portions Increased Physical Activity

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How to Achieve a 500 Calorie/Day Deficit Simple substitutions in everyday foods can greatly reduce caloric intake Reduced calorie foods Whole Milk (1cup) Skim Milk Caloric Decrease 150 101 49 Coke (1can) Diet Coke Caloric Decrease 150 1 149 Sugar Packet Splenda Caloric Decrease 15 0 15 Crispy Chicken Sandwich (McD’s) Grilled Chicken Sandwich (McD’s) Caloric Decrease 500 420 80 Yoplait Original (6oz) Yoplait Light Caloric Decrease 170 100 70

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How to Achieve a 500 Calorie/Day Deficit Although these differences are obvious to us , it is not always obvious to them . Reduced calorie foods Great benefit of weight management by calorie awareness is that virtually everything you buy has calories per serving listed on the label. There are many books available that list calories for just about anything you can eat. This is especially valuable if you dine-out regularly. This book is $6.99 from Barnes and Noble.

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How to Achieve a 500 Calorie/Day Deficit Favorite foods don’t necessarily have to be given up if the size of the portions is reduced. Reduced portions Serving Sizes Then and Now Food or beverage 1950s Expanded 2003 portion French fries 2.4 ounces up to 7.1 ounces Fountain soda 7.0 ounces 12 to 64 ounces Hamburger patty 1.6 ounces up to 8.0 ounces Hamburger sandwich 3.9 ounces 4.4 to 12.6 ounces Muffin 3.0 ounces 6.5 ounces Pasta serving 1.5 cups 3.0 cups Chocolate bar 1 ounce 2.6 to 8 ounces Consumers demand larger portions for their money to feel like they’re getting a better deal (usually larger sizes can be purchased for pennies more). www.mealmatters.org

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How to Achieve a 500 Calorie/Day Deficit Reduced portions So what is the difference between that super-sized McDonald’s fries and the small? Super Sized: Small: Difference: 610 kcal 250 kcal 360 kcal

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So What Do We Tell Them About Their Diet? Be aware of the calories in foods they eat Low-calorie substitutions where possible If they just have to get that extra large meal because it’s a better deal, splitting it with a friend/family member is perfectly acceptable – and so are leftovers. Focus on smaller portions

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How to Achieve a 500 Calorie/Day Deficit Increased Physical Activity The American Heart Association, the US Surgeon General, the Centers for Disease Control and Prevention (CDC), and the American College of Sports Medicine recommend at least 30 minutes per day of at least moderate-intensity physical activity on most, and preferably all, days of the week . The CDC, American College of Sports Medicine, and Surgeon General further state that physical activity may be incorporated into one’s everyday lifestyle and that the daily physical activity requirements may be accumulated over the course of the day in short bouts of 10 to 15 minutes. Circulation (AHA) – December 2006

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How to Achieve a 500 Calorie/Day Deficit 1 Calories burned per hour will be higher for persons who weigh more than 154 lbs (70 kg) and lower for persons who weigh less. Source: Adapted from Dietary Guidelines for Americans 2005 . Source: Adapted from Dietary Guidelines for Americans 2005

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Do housework yourself instead of hiring someone else to do it. Work in the garden or mow the grass. Using a riding mower doesn't count!  Rake leaves, prune, dig and pick up trash. Go out for a short walk before breakfast, after dinner or both!  Start with 5-10 minutes and work up to 30 minutes. Walk or bike to the corner store instead of driving. When walking, pick up the pace from leisurely to brisk. Choose a hilly route. When watching TV, sit up instead of lying on the sofa. Better yet, spend a few minutes pedaling on your stationary bicycle while watching TV. Throw away your video remote control. Instead of asking someone to bring you a drink, get up off the couch and get it yourself. Stand up while talking on the telephone. Walk the dog. Park farther away at the shopping mall and walk the extra distance.  Wear your walking shoes and sneak in an extra lap or two around the mall. Stretch to reach items in high places and squat or bend to look at items at floor level. Keep exercise equipment repaired and use it! Increased Physical Activity at Home www.americanheart.org

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Brainstorm project ideas with a co-worker while taking a walk. Stand while talking on the telephone. Walk down the hall to speak with someone rather than using the telephone. Take the stairs instead of the elevator. Or get off a few floors early and take the stairs the rest of the way. Walk while waiting for the plane at the airport. Stay at hotels with fitness centers or swimming pools and use them while on business trips. Take along a jump rope in your suitcase when you travel.  Jump and do calisthenics in your hotel room. Participate in or start a recreation league at your company. Form a sports team to raise money for charity events. Join a fitness center or Y near your job. Work out before or after work to avoid rush-hour traffic, or drop by for a noon workout. Schedule exercise time on your business calendar and treat it as any other important appointment. Get off the bus a few blocks early and walk the rest of the way to work or home. Walk around your building for a break during the work day or during lunch. Increased Physical Activity at Work www.americanheart.org

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Of all of these, walking is something that can be done everyday. Walking the inside perimeter of the mall or Wal-Mart is safe and can be done during inclimate weather. There are 206,000 sq ft of shopping area at P.B. Wal-Mart That’s a perimeter of 1,800 ft. Three trips around is just over 1 mile.

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For sedentary patients, a comment such as, "It must be hard to stay physically active with all the time you need to spend at a desk job," may open the door to a discussion about exercise. A description of the current guidelines promoting 30 minutes of moderate-intensity activities on most days of the week could dispel the notion that exercise must be a hard, sweaty chore that must be crammed into already busy days. Something as simple as writing a prescription for exercise (walk briskly at least five days a week, covering a mile in 15 to 20 minutes) demonstrates to the patient the importance of physical activity. AFP Journal – May 2004 Our Role is to Encourage and Educate Them

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“A body at rest tends to stay at rest until acted on by an external force. Let's be that external force.” Stephens Editorial – AFP Journal – March 2002