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OBESITY MANAGEMENT - UNIT 3
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What could be the solution?
Fasting and Modified Fasting Diets
Set a Realistic Goal
Shed Off Excess Fats
Modifying Food Choices
Article Review
Video Review

OBJECTIVES:
  • Identify proven solution to overweight and obesity
  • Describe fasting and modified fasting diets
  • Discuss lifestyle interventions to manage obesity including behavior change
REFERENCES:
  • Brenda Davis, RD.  Kick Diabetes Essentials, 2019.
  • Dean Ornish, MD. Undo It, 2019.
  • Michael Greger, How Not to Die, 2015.
  • European Association for the Study of Obesity

Approximately 90 percent of people with diabetes are overweight or obese.  Shedding just 5-10 percent of initial body weight can improve insulin sensitivity, glycemic control, blood pressure, and blood lipids in people with type 2 diabetes.  Depleting fat stores is a prerequisite for reversing diabetes, but even relatively small decreases in fat stores, especially visceral fat stores, will help to improve insulin sensitivity.  People eating 100 percent plant-based or vegan diets have the lowest rates of overweight and obesity of all dietary categories.
Overweight and obesity are defined as excessive fat accumulation, resulting in weight that is higher than the healthy range for any given height.  There is no one ideal weight for a person of a particular height because healthy weight depends on bone structure, muscle mass, body fat, and body build.  However, there are tools that can help you determine if you're carrying excess weight.  The most accurate method is to determine how much of your body weight is fat.  Body fat more than 17 percent in men and 27 percent in women indicates obesity.

Unfortunately, getting accurate body-fat measurements can be inconvenient and costly.  More commonly, a simple tool called Body Mass Index (BMI) is used to estimate total body fatness.  It is important to note that BMI is not a diagnostic tool, as it doesn't always accurately predict fat mass.  However, BMI is strongly correlated with adverse health outcomes, so it does serve as useful tool.  The key limitation to BMI is that it doesn't take into account differences in body composition between genders, racial and ethnic groups, or gender who have denser, more muscular builds, it is less reliable.  Thus, for many men and some women, a BMI of 25-27 could be very healthy.  For such individuals, shifting the cutoffs up by two points could improve accuracy.  Likewise for individuals with smaller bone structures and muscle mass, the BMI range may need to be adjusted down a couple of points.  This is especially true for Asians, who are commonly at increased risk of disease when they are within, but closer to the top, of the healthy BMI range (23-24.9).

From a physiological perspective, we are all unique.  Some people are metabolically efficient - they are designed to survive famine.  Unfortunately, those who are best able to survive famine are the least able to survive excess.  For these individuals, moderate food intake and vigorous physical activity are necessary to avoid weight gain.  Less commonly, overweight and obesity are triggered by hypothyroidism or the use of medications that can slow metabolism, increase appetite, or cause water retention.

It doesn't help that our environment is becoming increasingly obesogenic - likely to cause obesity.  Hyperpalatable foods infused with sugar, fat, and salt beckon us at every turn.  These flavors once gave us the assurance that our food supply was safe and nourishing, but they're only present in small amounts in nature.  When concentrated and used as principal ingredients in processed foods, our innate ability to control appetite becomes unhinged.  There is no mere coincidence.  These food components are purposefully concentrated in processed foods to keep us coming back for more.  

For many individuals, overweight has more to do with emotions than physical hunger.  Not only do we celebrate joy, excitement, success, victory, good news, and special occasions with food, we numb pain of difficult interactions, disappointment, embarrassment, stress, boredom, and overwork with food.  Emotional eating, in its most severe form, can lead to eating disorders, such as compulsive overeating or binge eating.

What could be the solution?

Diets are generally designed to produce a calorie deficit or to ensure that you take in fewer calories than you burn so you will lose weight.  Most diets succeed in this task.  All sorts of creative food combinations can work, as long as they leave you with caloric deficit.  If more diets succeed in producing weight loss, why do the vast majority fail for the long term?  The answer is simple:  they end.  If there is no plan for lifelong lifestyle change, old habits return, as does the weight.  So while some more extreme diets, such as modified fasting regimens, can and do work to rid the body of stored fat and restore insulin sensitivity, they need to be carefully paired with permanent diet and lifestyle changes in order to get permanent results.

Fasting and Modified Fasting Diets

Humans have a very remarkable ability to survive the absence of food through a series of physiological adaptations.  When the body is deprived of nutrition, it turns to its body stores.  Within twenty-four to forty-eight hours, its very limited stores for glucose (glycogen) are used up.  It is absolutely critical that blood glucose levels are maintained, as some body tissues (such as red blood cells and liver cells) can use only glucose as a fuel, so the body turns to stores of protein and fat, transforming them into glucose through the mechanism called gluconeogenesis (meaning "generation of new sugar").  Although some of the newly manufactured glucose is made from amino acids (muscle tissue) and lactate (a glucose breakdown product), most comes from fat stores.

Fat is used preferentially because it contains concentrated energy reserves and is expendable.  Fats are stored mainly as triglycerides, which are composed of three fatty acids attached to a glycerol backbone.  It is the glycerol part of the molecule that is used to make glucose.  Long-chain fatty acids can't be used as direct energy sources, so they are converted into short-chain fatty acids and ketones, which can be used for energy by the brain, muscle, and other body tissues.

One of the key adaptations of food deprivation is reduced inflammation and autophagy of body tissues and organs to reduce energy expenditure.  IN addition, the body attempts to rid itself of damaged or deranged cells.  Upon refeeding, stem-cell-based regeneration of a portion of these cells takes place.  Some evidence suggests that this process can result in the regeneration of pancreatic beta cells, which is exciting news for anyone who has a reduced ability to make insulin.

For individuals with type 2 diabetes, any type of fasting program requires close medical supervision, particularly if the individual is on insulin or other medications.  Because true fasting or water fasting eliminates all foods, it should only be carried out in a treatment facility with medical monitoring, especially when the fast is extended for more than few days.  Modified fasts that allow some caloric beverages or food  are generally safer choices.  However, these regimens are not nutritionally adequate long term, so if they are used, they need to be carefully controlled.  A comprehensive weight-loss strategy needs to be included, as well as ongoing support.  There are three popular variations on fasting or modified fasting.

TIME-RESTRICTED FEEDING (TRF)
This method of modified fasting restricts food intake to a limited window of time in a twenty-four-hour period.  Regimens restrict eating for fourteen to twenty-two hours each day, allowing a range of two to ten hours for eating.  With fourteen hours of fasting, you would stop eating after dinner (say at 6:00 or 7:00 pm) and not begin eating again until 8:00 or 9:00 a.m. the next morning.  with a sixteen-hour fast, you would eat only two meals a day.  The first could be at 10:00 or 11:00 a.m. and the second at 5:00 or 6:00 p.m.  With a twenty- to twenty-two-hour fast, you could consume just one meal a day.  Of course, your meals would be healthy, high in fiber, and plant-based.

INTERMITTENT FASTING (IF) OR INTERMITENT ENERGY RESTRICTION (IER)
This is a type of modified fast that involves full-day food abstinence or restriction, but only on specified days of the week.  So, for example, you might do a fast or modified fast one day a week or eat normally for five days and then fast for two consecutive days; this is called a 5:2 regimen.  some intermittent fasts involve a fast or modified fast every other day.  Intermittent fasting may be done using water fasts, juice fasts (with fresh vegetable juices), or very low-calorie diets.

PERIODIC FASTING
This type of fasting is based on extended periods of food abstinence or restriction, such as four to five days at a time.  Periodic fasting can be done using water-only fasts under supervision, juice fasts, or very low-calorie diets.  One of the most popular periodic fasts is what is commonly referred to as a fast-mimicking diet.  Even though percentage of calories from carbohydrates is higher that it is on ketogenic weight-loss diets (about 30 percent of calories compared to 5 percent), it still produces ketosis because total calories are very low (about 1,100 calorie on day one and 800 calories for the next four days).  Participants follow a modified fast for the five days, then eat a higher-fiber, plant-based diet for twenty-five days.  For someone with diabetes, at least three fasting cycles are recommended or as many as are needed to achieve the desired results.

Set A Realistic Goal

The first and most critical step to permanently overcoming overweight or obesity is to redirect your focus from thinness to health.  Restoring health must be your top priority.  Remember that every single cell of your body is the product of the food that you put into your mouth - your food serves as your basic structural material.  Resist the urge to select foods on the basis of their caloric content or perceived effectiveness as diet foods.  Instead, select foods on the basis of their ability to nourish and protect your body.  Before you bite into sugar-free "diet" cookie, ask yourself whether white flour, processed vegetable oil, and artificial sweeteners are the best materials with which to rebuild your brain cells.

There is no question that weight loss requires a decrease in energy input and an increase in energy output; in other words, you must eat less (fewer calories) an move more.  But this is only one prerequisite.  It's also important to reestablish an environment that will effectively reset metabolic machinery.  One of the greatest challenges in the quest for wellness is to break old, destructive habits and replace them with habits that truly support and promote health.  For example, if you descend into an abyss of junk food while watching television after dinner, consider the possibility of filling your evenings with dancing, walking, bird-watching, pottery classes, or whatever else tickles your fancy.  The plan must involve creating a new routine and following that routine robotically for a set period of time - one month is a good goal.  If you set a time frame for yourself, it will make sticking to the routine a little easier.  Once you've repeated a behavior for a month, you'll be well on your way to turning it into a good habit for life.  To make your plan foolproof, be sure to surround yourself with a strong support system.

Think positively.  It is more important to be on the right path, inching your way to your goal, than to worry about how far along you are on the path.  Listen carefully to your body, as it communicates with you constantly, honestly, and openly.  Let it guide you as you gradually reclaim your health.  On this journey there are no interviews, no exams, and no reprisals.  There is nothing to feat.  Take on only what you are able and ready to take on.  Be prepared for stumbling blocks and resistance.  Don't beat yourself up when things don't go according to plan.  Instead, use each disappointment as a valuable lesson about what works and what doesn't.

Shed Off Excess Fats

Shedding excess pounds and reclaiming your health may feel like the most challenging journey of your life, but it is equally rewarding.  Set goals and focus on those that will get you to your destination - improving your fitness level; increasing your fiber intake; eating more leafy greens and beans; stabilizing blood glucose levels; reducing blood pressure, blood cholesterol, or triglycerides; managing stress; improving energy; curtailing mood swings; overcoming addictions; and getting enough rest.  Get rid of the food and other items that tempt you, and restock your pantry with foods that are consistent with your health goals.  If a person have been a junk-food or fast-food eater, they can join a whole-foods, plant-based cooking class.

Modifying Food Choices

Here's a simple list of things you can do to shed excess pounds and, more importantly, sustain the weight loss for a lifetime.  Once you make them part of your daily routine, following the list will become a healthy habit.

EMPHASIZE FOODS WITH A LOW CALORIC DENSITY
Foods with a low caloric density are those that take up a lot of space on your plate and in your stomach but pack few calories per bite.  Foods with the lowest caloric density are nonstarchy vegetables, which provide about 100 calories per pound (0.45 kg).  Eat them liberally.  Foods with moderate caloric density should be included to ensure that you feel well fed and are well nourished.  This includes fruits, which provide about 300 calories per pound (0.45 kg), as well as legumes, starchy vegetables, and whole grains, which provide 400-600 calories per pound (0.45).  Calorically dense healthy whole foods, such as avocados, nuts, and seeds, should also be included but in small amounts.  Calorically dense flour products, and fried foods are what needs to go.  Concentrated fats and oils provide about 4,000 calories per pound (0.45) and are also best excluded.  The only foods with lower nutrient density are sugars.

EMPHASIZE FOODS WITH A HIGH NUTRIENT DENSITY
Foods with a high nutrient density are those that provide the greatest amount of nutrients per calorie.  Some nutrient density indexes, such as the Aggregate Nutrient Density index (ANDI) by Joel Fuhrman, MD, also factor in fiber, plant sterols, phytochemicals, and antioxidants.  Using the ANDI score, nothing compares to green leafy vegetables.  All whole plant foods are nutrient-dense choices - vegetables, fruits, legumes, whole grains, nuts, and seeds.  Foods with the lowest nutrient density, such as sweet beverages, oils, and deep-fried foods, will work against your quest for health and are best avoided.

FOCUS ON FIBER ON YOUR PLATE EVERY MEAL
Fiber keeps you full, maintains regularity, feeds your gut bacteria, and moderates your blood glucose.  The foods highest in fiber are legumes.  Other fiber-rich choices are whole grains, vegetables, fruits, nuts, and seeds.  Include these on yor plate at every meal.

FILL YOUR PLATE WITH WHOLE PLANT FOODS
Whole plant foods don't come with an ingredient list.  What you see is what you get.  Aim for at least sever servings of nonstarchy vegetables, three servings of legumes, and three servings of fruits each day.  Eat moderate portions of grains and starchy vegetables based on your energy (calorie) needs.  For weight loss, intakes may be as low as two or three servings a day.  Nuts and seeds are very high in calories, so use small portions - one to two servings per day.  Eat these as they're grown - unprocessed.

ELIMINATE ULTRAPROCESSED FOODS
Ultraprocessed foods are made entirely or predominantly from non-nutritive substances extracted from foods - starch, oil, additives, colors, flavors, and preservatives.  Most are based on refined carbohydrates and refined fats.  These foods are subjected to many layers of commercial preparation.  Not all processed foods are off-limits.  Minimally processed foods, such as frozen herbs, some sprouted breads, washed and packed greens, canned beans, and some jarred sauces can make food prep a little easier.  Read the ingredient list!

MINIMIZE THE USE OF CONCENTRATED SWEETENERS AND AVOID ARTIFICIAL SWEETENERS
Humans are naturally attracted to sweet tastes.  whether the sugar comes from high-fructose corn syrup or organic dehydrated cane juice matters less than the amount of sugar you ingest.  Regardless of the source, sugar is sugar, and it indicates empty calories with little or no other nutrients.  If you're using a packed food, read the label.  Avoid artificial sweeteners; they provide no real assistance in your quest for health and may negatively affect metabolism, microbiota, and appetite control.  If you do use a sweetener, monk fruits and stevia derivatives would be the best options. 

MINIMIZE CONCENTRATED FATS AND OILS TO AVOID SOLID FATS
Fats and oils are extracted from whole foods.  During this process, fat-soluble vitamins, minerals, phytochemicals, and fiber are left behind.  Extracted fats and oils, white flour and sugars are highly processed foods with most of their nutrients removed, and it's best to minimize their use.  Fats and oils contain about 120 calories per tablespoon (15 ml), which is about two and on-half time more than pure protein or carbohydrate.  Avoid solid fats, such as margarines and coconut oil, as they are particularly high in saturated fat.

MAKE THE MOST OUT OF HERBS AND SPICES
Herbs and spices are the most recently hailed health heroes.  They not only make food taste better, but they also do so without adding sodium or fat.  Several herbs and spices have shown some promise as weight-loss allies due to their ability to boost metabolism, calm inflammation, or balance blood glucose levels.  Among the spicy superstars are black pepper, cardamom, cayenne, cumin, cloves, cinnamon, ginger, mustard seeds, oregano, rosemary, and turmeric.  Grow your own herbs on your windowsill; they are hardy plants that can be enjoyed year-round.  Herbs can be frozen or dehydrated for later use.

DRINK WATER, NOT SUGAR
Sweet beverages are loaded with calories.  A 12-ounce (375ml) of lemonade, fruit punch, or soda contains 120-150 calories.  A 12-ounce (355 ml) beer provides 110-170 calories; distilled spirits, about 110 calories per 1.5 ounces (45 ml); liqueurs, 150-190 calories per 1.5 ounces (45 ml); and wine, about 80 calories per 4 ounces (120 ml).  Water is our best thirst quencher and is calorie-free.  Herbal teas are also good choices.  it is best to avoid getting calories from beverages, as they don't provide satiety the way that solid foods do.

The one exception is fresh-pressed green vegetable juice, which has a unique value as an antioxidant booster.  If you consume nondairy milks, select those that are unsweetened.  If you include smoothies, be very selective with ingredients, and use them as meal replacements (not as snacks) no more than once a day.  Avoid calorie-free beverages containing artificial sweeteners.  These beverages seem to confuse our appetite control center and metabolic hormones and are of no value to health.

Article Review

Health Behavior Change for Obesity
Intermittent Fasting and Weight Loss
Endocrine Changes in Obesity

Video Review


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