the duke diet and fitness center welcomes duke … duke diet and fitness center welcomes duke food...
TRANSCRIPT
The Duke Diet and Fitness Center
Welcomes
DUKE FOOD WORKING GROUP
October 8, 2014
Putting the Pieces Together: An Intensive,
Multidisciplinary Obesity Treatment Model
DUKE DIET and FITNESS CENTER
GUIDING PRINCIPLE: We need to make permanent, sustainable changes in both food intake and physical activity to lose weight, maintain weight loss, and live a healthier lifestyle
DIET and FITNESS CENTER PROGRAMS:
• Residential weight loss program
– New clients
– Return clients
• Optifast
• Outpatient medical, dietary, and behavioral health consults
• Research
DFC Residential Weight Loss Program Overview
• One-, two-, three-, and four week programs
• Clients from all over the US (and around the globe) to Durham- stay in hotels in the area
• Clients spend all day at the DFC– Building opens at 7AM and closes at 9PM
– Three meals daily + snacks (breakfast and lunch Sat and Sun)
– Exercise classes
– Classroom lectures
– Free time for individual exercise, study, etc.
– Massage, acupuncture, physical therapy, etc. are available
DFC Clients
• Average age: early 50s
• Age range: late teens to nineties
• Gender: 60% women, 40% men
• Average BMI: 38 kg/sq m
• Clients are typically well educated, well informed, upper socioeconomic status, highly motivated to make lifestyle changes
DFC Residential Weight Loss Program Overview
• Four components
– Medical
– Nutrition
– Fitness
– Behavioral Health• All new clients are assessed by professionals in each component during
first few days
• Each component offers classroom lectures in its area of expertise
• Clients return to professionals in each component throughout their DFC programs for check in visits, questions, progress reports, etc.
DFC Residential Weight Loss Program Overview
• Attended by all DFC Treatment Staff (all members of all four components plus Patient Advocate)
• Every week each incoming client is presented and discussed
• Clients who may need special attention or additional evaluation are identified
• Current clients who are not losing weight, are missing meals, are not exercising, etc., are also discussed
• Goal is to have every client be successful!
Weekly Patient Care Conference
DFC Medical Component
• MD and FNP
• Intensively address all obesity related comorbidities
• Serve as Primary Care Providers for clients while at the DFC
• Arrange consultations with Duke specialists
• Lectures
– Overview of Obesity
– Diabetes
– Hypertension
– Lab Interpretation
– Preventive Medicine
– Osteoarthritis
– Weight Loss Medications/Weight Loss Surgery
DFC Outpatient Options
• For local residents
• Outpatient consults for weight loss by
– Medical staff
– Nutrition staff
– Behavioral health staff
• Optifast full and partial meal replacement programs
Putting the Pieces Together:
Nutrition
Developing an Effective, Sustainable
Eating Plan for Long Term Success
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The Diet
• 3 meals daily, snacks optional
• Calorie & Portion based
– 1000 – 1500 kcal
• Clients plan their own menu
– Flexible food choices/diet plans to individualize program
– Gain meal planning skills
– Sustainable, realistic
Food Service
Meriwether Godsey
• Based in Lynchburg, VA
• Local ingredient sourcing as much as possible
• Fresh, scratch made
• Limit use of disposables
– Recycled/Recyclable or compostable
• Limit food waste
– Prep based on menu tally
– Compost food scraps
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Nutrition Treatment Plan
• Nutrition Staff: 2 Registered Dietitians (RD/RDN)
• Week one: 1 hr with RD– Weight & dieting history
– Medical concerns r/t nutrition (diabetes, cholesterol); meds & supplements
– Healthy eating barriers
– Typical daily diet
– Calculate RMR, review calorie prescription
• Optional weekly check-ins (15-30 min)– Monitor progress/tweak
menu
– Answer questions
– Plan for return home
• Support at Home– Dietitian on Demand
– DFC Blog & Facebook
– Recipe updates
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Common Nutrition Related Challenges
What?
• Skipping meals
• Lack fruits & veggies
• Frequent restaurant & processed foods
• Mindless eating
• Emotional eating
• Uncontrolled portions
• Yo-yo & all/nothing dieting
Why?
• Lack of time
• Don’t plan ahead
• “Healthy” foods perceived less convenient
• Temptation (food environment)
• Lack hunger awareness
• Conflicting nutrition information
• Low interest or ability to cook
Nutrition Curriculum
• Nutrition Fundamentals
• Calories & Portions
• Restaurant Strategies
• Grocery Shopping
• Cooking
• Mindful Eating
• Mindless Eating
• Meal Planning
• Volumetrics
• Special Topics
– Fish
– Heart healthy eating
– Power foods
– Anti-inflammatory diet
– Vitamins & minerals
– (Coming soon): Nutrition myths/controversies
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Research/Collaboration Ideas
• Resting Metabolic Rate testing
– Working on IRB proposal
– Prediction Equations, Indirect Calorimetry, RMR, and Obesity
• Diet comparisons
– Varying diet composition (macronutrients; processed foods; artificial sweeteners)
– Effects on gut micro flora
– Long term vs. short term
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Putting the Pieces Together:
Behavioral Health
Building a Bridge Between
Knowledge and Action
From Knowledge to Implementation
I know what I should do…
I just don’t do
it..
If only I had
more time…
If only I felt more motivated
If only…
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Behavioral Health Services at DFC
• Initial 50 minute assessment with one of our clinicians
• Weekly 20-min check in sessions to follow up, answer questions, prepare for home
• Lectures and Groups
• Individual sessions
• Case management during the program
• Outpatient consultation, psychotherapy, post bariatric surgery assistance
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Barriers to Healthy Lifestyle Change
• Too many social events with food and drinks
• Emotional eating
• Lack of support (food/exercise police or the enabler)
• All or nothing mentality
• Unrealistic expectations
• Mood disorders
• Disordered eating (binge eating)
Behavioral Health: Tool Box for Success
• Make lifestyle change a priority (time mgmt)
• Self-monitoring and accountability
• Develop healthy mindset
• Address depression/anxiety/grief
• Managing cues in the environment
• Stress management
• Coping skills for negative emotions
• Realistic goal setting
• Mindfulness
Examples of Behavioral Health Lectures
• Overcoming Emotional Eating
• Stress Management
• Action Planning for Success in the Real World
• Controlling Overeating and Binge Eating
• Enlisting Social Support
• Mindful Awareness Training
• Willpower and Skillpower
• Group: Looking Deeper at Emotional Eating
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Identify Specific Goals and Visions
• Build confidence and hope
• Not just weight loss goals, but lifestyle goals
• Focus on desired outcomes, not what “you don’t want”
Identify Challenges to Implementation and Focus on Specific Action to Follow Through
• If I’m tempted to eat when I’m feeling lonely…. Then I will
– Reach out to a friend that can give me support
– I will remind myself of other times I made it through
– I will reach for something healthy
Preparing for Future Challenges and Set Backs
• Learning from setbacks
• Lifestyle Coaching for ongoing support
• Weekly teleconferences to stay connected with DFC
Putting the Pieces Together:
Fitness
Getting Started in the Right
Direction
Fitness Planning at the Duke DFC
Part 1: Who We Are FITNESS PROFESSIONALS
(Clinical) Exercise Physiologist
Exercise/Fitness Specialist
Certified Personal Trainer
Degrees: Exercise Science/Physiology, Phys Ed/Adult Fitness, Wellness, Health & Human Performance
Certifying Organizations
• ACSM (American College of Sports Medicine)
• NSCA (National Strength and Conditioning Association)
• NASM (National Academy of Sports Medicine)
• ACE (American Council on Exercise)
• Physical Mind Institute, Stott Pilates, etc
Recommended for those requiring exercise supervision/monitoring
Part 2 : What We BelieveOUR PHILOSOPHY
The guiding principles
Exercise & consistent PA are essential to weight control, disease prevention and a healthy lifestyle.
Learn to exercise effectively, safely and successfully. Add more movement to daily life. Create a schedule that fits “your lifestyle”.
Greater focus on PA & benefits of aerobic, strength, and flexibility exercise.
Find who “you” are as an exerciser, explore new ideas,
practice what you can/will do at home.
Part 3 : What We DoFITNESS PROFESSIONAL’S ROLE
• Pre-exercise clearance (including motivation)
– Stress test
– Orthopedic/PT consults
• Fitness Assessment
• Develop relationship with patient
• Guide/Coach patients through planning process for exercise at home
• Goal Setting for home
Typical DFC Fitness Assessment
• Review Medical History (CAD, HTN, DM)
• Orthopedic Limitations/Concerns
• Current PA level (last 3 months) & Past Exercise History
• PA Barriers (internal & external)
• Initial Action Plan for home
• Physical Activity Goals (not weight loss goals!)
• Exercise Prescription: Frequency, Intensity, Time, Type
– At what level/environment will patient succeed (@DFC/@home)?
– Should patient work independently? With Physical Therapy?
Common Orthopedic Concerns and Recommendations
OA
Meniscus
Tendonitis
KNEE LOW BACK HIP
OA
Sciatica
Disc Injury
Bursitis
Rotator Cuff
Quad strength
Core strength/ stability
Flexibility of quads, hamstrings, hips, IT
band
Core strength/ stability
Flexibility of low back, hips, hamstrings
Abductor/Adductor strength
Core strength/stability
Internal/External rotationWeight loss typically leads to some level of
improvement of many orthopedic issues.
OA
Bursitis
Stage of Change Action
Precontemplation Not ready to exercise
Encourage patient to consider exercising; tell patient about health benefits of exercise.
Contemplation Interested in/thinking
about exercise
Independent Supervision Necessary
Write Rx; refer to non-clinical professional
Refer to clinical exercise professional
Preparation Exercising less than
recommended amount
Write Rx; refer to non-clinical professional
Refer to clinical exercise professional
Action & Maintenance Exercising
recommended amount
Encourage continued exercise
Refer to clinical exercise professional
www.ExerciseIsMedicine.org
Physical Activity & Motivation
30 min moderate-intensity cardio; 5 days/wk-OR-
20 min vigorous-intensity cardio; 3 days/wk
ACSM/AHA
Is this optimal for weight loss and/or maintenance?
Weight management guidelines:
60 minutes moderate intensity activity most days
INSTITUTE OF MEDICINE
Physical Activity & Health Guidelines
Frequency Intensity Time Type
Aerobic 4-6 days/wk 50-85% HRR60-85% HRmax
11-14 RPE
Accumulated30-60 mins/day
200-300 mins/wk
Large muscles, rhythmic, continuous
Strength 2-3 days/wkNon-consecutive
Volitional fatigue. Final 2-3 reps should be challenging
1-3 sets8-15 reps20-45 minutes
8-10 exercises; include all major muscle groups
Flexibility 2-3 days/wkminimum
Point of mild discomfort, but not pain
15-30 seconds each stretch; 2-4x/stretch
Static stretching
Neuromotor“Functional”
>2-3 days/wk Challengeappropriate to the individual
>60 mins/wk Balance, coordination,gait, agility
Activities of Daily Living (ADLs)
Use pedometer to establish baseline # of steps; gradually increase toward average of 10,000 steps/day.
EXERCISE GUIDELINES FOR
WEIGHT MANAGEMENT
Class Offerings – Activity & Lecture
• Aqua Aerobics/Aqua Force
• Cardio Interval / Circuit
• Step / Kickboxing
• Chair Aerobics
• Pilates
• Strength, Balance & Stretch
• Gyrokinesis
• Boot Camp
• Restorative Strength (Yoga, Foam Rollers, Pilates)
• Fitness Fundamentals
• Exercise Metabolism
• Getting FIT with Technology
• Components of Fitness (Strength & Flexibility)
• Making Peace with Exercise
• Whats Wrong with My Back? Knee? Shoulder?
Recommended Activities
Aerobic Walking (treadmills/outdoor), biking, elliptical, NuStep, group fitness classes (land & aquatic), swimming
Strength Machine circuit, free weights, resistance bands/tubes, bodyweight, medicine balls, stability balls, water resistance, kettlebells, TRX, BOSU
Flexibility Stretching, yoga, Pilates, Tai Chi, foam rollers, gyrokinesis
Neuromotor“Functional”
Balance discs, BOSU, balance mats/beams, tandem stance/walk, strength exercises combined with balance, Tai Chi, yoga, TRX
ADLs Stairs, short walk breaks at work, park car farther away, housework, yardwork
Sports & Recreation
Tennis, golf, hiking, dancing, kayaking, bowling, Wii
EXERCISE GUIDELINES FOR
WEIGHT MANAGEMENT
Intervention
• Physical activity goal setting (not weight loss goals!)
• Tracking– Garmin Vivofit, FitBit, journal, pedometer, smartphone apps
• Positive support
• BodPod testing
• Educating clients for accurate metabolic expectations
Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it.
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Q & A