Hélène Charlebois, RD HC Nutrition Inc. Consulting & Wellness Weight Management Specialist

1. Hélène Charlebois, RD HC Nutrition Inc. Consulting & Wellness Weight Management Specialist Certified in Adult Weight Management Level 1 & 2 Academy of Nutrition & Dietetics (ADA) Waisting AwayTM 2012 Empowering “FUTURE” Health Professionals with Weight Management Knowledge / Research / Practice for Health at ANY Size!

2. Research - Information Academy of Nutrition & Dietetics AND Weight Management Training level 1 & 2 + new certification ADA Weight Management DIPG Canadian Obesity Guidelines CON – Canadian Obesity Network Summit – attend & present on line newsletter, research DC Obesity Learning Retreat Blogs by Dr Arya Sharma and Yoni Freedhoff Dr. Sharma's Obesity Notes » blog [amsharm@ualberta.ca] Weighty Matters [yonifreedhoff@gmail.com] New - points towards IASO’s Specialist Certification for Obesity Professional Education (SCOPE). www.hcnutrition.com

3. The 5 A’s of Obesity Management is a set of practical tools to guide primary care practitioners in obesity counseling and management: • Ask for permission to discuss weight and explore readiness for change • Assess obesity elated health risk and potential “root causes” of weight gain • Advise on obesity risks, discuss benefits treatment options • Agree on realistic weight-loss expectations and on a SMART plan to achieve behavioral goals • Assist in addressing drivers and barriers, offer education and resources, refer to provider, and arrange follow-up

4. What are DIETS? Billions and billions of $$$ All diets work Recent research – 75 years of dieting Most weight loss is in the 1st 6 months Skills

5. Treating Patients What Docs say? Recommend to lose 21% of their weight UNREALISTIC ! Treat distress not depression On line – 80% want an in home diet plan Apps – in 2010 = $910 million Getting the church involved But… obesity cost was 4.6 Billion in 2008 (usa) and increase of 20% from 2000

6. National Weight Control Registry www.nwcr.wsfor sustainable weight loss Weigh 1x/week; do something about weight gain Planned and structured; eat similar foods Low calories/fat; 1800 cals + 30% fat Eat breakfast Eat out less than 3 x/wk; fried foods less than 1x/wk Active1 hour per day – simply move more! Less than 10 hours per week of “screen watching”

7. Measuring Obesity Waist Men = 102 cm ; women = 88 cm High risk: men = 90 cm ; women = 80cm South Asian & Aboriginal = High Risk Hip Waist to hip Anthropometric BIA – In Body – BOD POD- DEXA How to measure???

8. Bariatric Surgery Restriction of food Less eating – size of a golf ball Less food How to deal with comfort eating Malabsorptive Malnourishment – pre and post Macro / micronutrients Neural & Hormonal Pathways

9. Bariatric Surgical Options30 to 80% loss EBW Expanding in Canada Surgery - 5 different procedures Adjustable Gastric Banding Roux en Y gastric bypass – less 50% EBW/ 1st yr Biliopancreatic Diversion/duodenal switch Sleeve Gastrectomy Gastric Ballooning / Endo Barrier What about Fatty Liver Disease? Correcting for Vitamin D deficiency

10. Bypass- 80% ebw 2 Multivitamin mineral for life Iron , folic acid and B12 (1200 mmg) Take Vitamin C 500 mg with Iron 300 mg 1 to 3/day Calcium 1200-2000 mg elemental calcium Liquid or tabs – Citrate is best No take more than 500 mg at a time Take even if 2-4 servings of dairy per day Vitamin D – make sure in Calcium Supp. At least 1000 IU/day Protein = calculate needs 0.8-1.0 g per kg; 0.91 g/kg actual body weight; 1.5-2.1 g/kg ideal body weight B12 over time – doc to assess 500 mcg sublingual

11. Why the Weight Loss in Surgical Patients? At 1 month = decrease in gut hormones then stable GLP1, incretins, GIP, Amylin, Glucagon, Proinsulin, C peptide At months 2 to 12 = decrease FBS, insulin, decrease in food and absorption Stomach + intestines = largest endocrine system ‘CURE’ for diabetes?

12. Staging System – Dr.A Sharma Need for a better diagnostic system 0 – obese but not risk factors 1 – subclinical factors, mild symptoms 2 – chronic disease, mobility limitations 3 – end organ damage- significant limits Impairment of well being 4 – severe disabilities

13. Hormones affecting weight Hunger stimulus Hedonic Homeostatic Appetite Do food addictions exist?

14. Cortisol - brain Fight or flight hormone Sleep deprived Screen watching Makes you hungry Increases belly fat Sleep patterns Sleep before midnight- most sleep before 530 am No eating after 8pm

15. Sleep Deprived Less sleep Increase hedonic stimuli = Increase food consumption Decrease leptin Increase ghrelin & cortisol Trying to reach glucose homeostasis Kids - teens

16. Insulin - pancreas Stores body fat High insulin levels = burns carbohydrates Low insulin levels = burns fat Therefore, we will burn more fat if eat less carbs

17. Dopamine – brain= Opioid syndrome The “chocolate” hormone Hypothesis Cravings- sweet tooth Similar to endorphins Obese = decreased receptors = decreased bliss point

18. Serotonin Brain Decrease in winter Feel good hormone Estrogen link Low serotonin Decreased hunger Increased anger SSRIs

19. Ghrelin – gut – hunger hormone Controls weight Controls glucose homeostasis Hunger and appetite The ONLY hunger hormone

20. Leptin- protein-hypothalmus Appetite suppressant Controls appetite Energy in Energy out gene Produced by fat tissue Obese has high leptin but it is resistant NEEDED: a system that will “sensitize” Dopamine Link?

21. Incretin- GLP1 – intestine Increase insulin secretion Decrease appetite Decrease glucagon Decrease sugar production by the liver Gets insulin ready New diabetes medication = Victoza,Byetta

22. % Weight Loss Diet & Exercise- Lifestyle 3 - 5 - 10 % Pharmacotherapy 5 – 10 - 15 % Bariatrics 20 - 30- +++ % up to 80% EBW

23. Food - the nutrient link is broken Food and in Food & Ingredients • Increase quantity of high quality foods • Decrease quantity of low quality foods Ready to EAT • Less protein, fibre, vits, mins • More sugar, fat salt • More energy

24. Making Changes –are they ready? HOW? WHY? HOW? • For what? • Healthier living • Healthier being • Disease prevention • Disease state management They came to you… level of readiness • Ask the question • Easy to lose weight but not easy to keep the weight off • Must be ready to make lifestyle lifetime changes More in Behavior section

25. Clean up your House WHY? HOW? • House needs to be a ”Positive Health Environment” • Set up for SUCCESS • Food availability is too high • Make it healthy • Get rid of your trigger foods – unsafe foods DANGER FOODS • Look into kitchen cupboards, fridge, pantry • Purge “unhealthy” foods • Office; desk drawer Replace with healthier food options

26. Successful Set Up WHY? HOW? • Must keep great tasting healthy foods around you • At all times • Increases your rate of success • Studies show… “out of sight out of mind” • Fruit & Veggie shopping • Bagged, trays, frozen, fresh, canned…it all counts • Keep some everywhere • Lean meats • Desk drawer • Legumes- new recipes

27. Choose only whole / sprouted grains Why? Change the box! • Eating whole grain, sprouted, high fiber foods • Keep you fuller, longer • Low GI • Are healthier for you • Refined processed starches digest quickly How? • Stick to whole grain, whole wheat product • Pasta, brown rice, crackers, cereal • No white rice-why? • Try different grains • Sprouted grains

28. No bagels??? No bananasNo white potatoes Why? Change the box! • Bagels- +300 calories • Available: low GI / 150 calories • Bananas and potatoes are favorites so take them out… make a change… you’ll be amazed! How? • Choose whole grain breads/ english muffins • Have any other fruit and any other vegetable.. Try to think outside the box… variety is key

29. Eat low GI Foods Why? How? • Keeps you fuller, longer • Generally higher fiber and healthier foods • Control blood sugars • Control cholesterol level • Gives some boundaries Take with a “grain of salt” • www.glycemicindex.com • www.diabetes.ca • Eat lots of whole fruits and vegetables • Eat whole grains • Eat lean meats and low fat dairy products • Add fiber to foods

30. Meal Balancing WHY? HOW? • Nutritionally adequate • All nutrients • More even distribution of starch and protein • See chart and guidelines • HEP sheet • Protein at all meals • More even distribution of starch to protein • Up to 25% protein • Have protein with PM snack

31. No Starch at Supper WHY? HOW? • Reducing the total calorie intake • Less cals at supper and beyond is key • Starch at supper = • Lots of calories • We LOVE starch • Insulin and belly fat • HS more sedentary • Replace your starches with vegetables • Use spaghetti squash • Use a bed of corn instead of rice • Use bean sprouts instead of pasta • Sweet potato/yams are great • Ok for starchy vegetables • Legumes are great!

32. Journaling WHY? HOW? • Awareness • Understanding • Patterns • Accountability But… most HATE journaling! • See the CFC sheet • Same as the “meal balancing” • Journaling sheet • Create own • Journaling book / on line • www.myfitnesspal.com • APPS : The Future!

33. Journaling continued Make journaling effective Pick your battles Be realistic Be flexible Different journaling strategies Only HS intake Only activity Only after lunch and beyond

34. Plan your Snacking WHY? HOW? • Small snack = eat less at meal times • Do not “rip the fridge door off” • Up to 40% total daily calories • Too often • Too much-portions • Too calorie dense • The 4th Meal! • Plan a small snack 1 hour before meals • AM= 80 calories • Yogurt, fruit • PM = 100 -150 calories • This is the important one • Protein + fruit/veg • HS = 100 -150 calories • Sweet/salty tooth

35. Calorie Distribution WHY? HOW? • Calories count • Recent research; all diets work in the short term • More even distribution throughout the day • See chart and guidelines • HEP sheet

36. Meal Balancing Meal balancing = It is important to have a protein at each meal; starches should be whole grains. BREAKFAST=300cals LUNCH=400-500cals DINNER=400-500cals Protein Starch 2 Vegetables Protein Fruit Starch Protein Starch 2 Vegetables Protein + fruit 100-150 calories Fruit snack snack snack HINT: For added weight loss, no starch at supper but load up on the veggies!

37. Calorie Distribution/Protein Breakfast = Starch 150 cals/20g am snack = 80 calories/10g Lunch=St.150 cals; prot.150 cals/20g pm snack = 100 to 150 calories/10g Supper = St. 0 cals to 300 cals/20g hs snack = 100 (150) calories

38. PROTEIN - U of Texas 20 to 30 grams at breakfast 20 to 30 grams at lunch 20 to 30 grams at supper NO MORE NO LESS! WHERE THE MEAT!

39. Reintroduce Starch at Supper WHY? HOW? • Because we like it! • There are special occasions • There are exceptions to every rule • BUT…. • No more than 2 times per week • 1 cup = 300 calories • Do not have the starch at lunch OR ½ cup at supper nightly Must be measured Reduce protein

40. Portion Distortion WHY? HOW? • Supersizing • More for less • Restaurant portions • The food container is simply too much • Our eyes are bigger than our stomachs Bottom line We just eat too much! • Label reading • Be visual • Change the plate • Show portions of food • Food models? calories • Measure it out • We are not good at eye balling Load up on veggies 2-3 fruit per day

41. Vegetable 1st on Plate WHY? HOW? • Our eyes are bigger than our stomachs • We always put more of the first item on our plates • Research Xmas • Put vegetables 1st on the plate • Then the protein • Lastly is starch

42. Set up Buffet WHY? HOW? • How you set up the plates • How you set up your counter for plate preparation It makes a difference • Always put veg 1st • Then protein • Last starch Try this at home… you will be AMAZED!

43. Eat close to farm WHY? HOW? • This is my motto • Very simple concept • Farm foods are usually: • Lower in calories • Higher in fiber • Bountiful • More filling • Keeps you fuller longer • More nutritious • Eat whole foods • If the food comes from the farm, eat it… if the food leaves the farm, judge it. • Give some examples • apple vs apple sauce vs apple juice

44. Damage control WHY? HOW? • We all “cheat” but our patients feel guilty about it • Feel good about it • Plan it • Move on • 2 types of damage • Planned = sandwich it in • Unplanned = 48 to 72 hours revenge Don’t get angry get even!

45. Eating Out WHY? HOW? • Because it is part of life • RUIN IT! Many handouts available ‘Heart & Stroke Ontario’ www.myfitnesspal.com • See internet • Plan choices on line • Do not take menu • Take away the guilt • Trading off choices • Move away from the bread • Order 1 item at a time TRAVELLING?

46. Beverages Count WHY? HOW? • Hidden calories • You would not believe • Portion distortion • Single serving sizes are just too big New journal Snack & Beverages • Labels for portion sizes • Show glasses, cups • Journal beverage intake for one week • Count calories on beverage intake • Clear on Calories Initiative Diet pop?

47. Why? Quick & Easy Controlled eating – no thinking Eliminate complex food choices Eliminate complex meal planning Meal Replacements (cont’d) Waisting Away TMWeight Management Strategies

48. What about Protein Shakes? Stomach = volume detector Intestine = nutrient detector Saliva = brain –nutrient detector Chewing & Tasting

49. Exercise / Activity STRUCTURED UNSTRUCTURED Anti-Sedentary Movement % effect on weight loss? Weight is Food; Health is FOOD & FITNESS

50. Cardio How to do it • Walk, run, bike • Group sports • Soccer, hockey • Family Fun • Skating, skiing, tobogganing , biking What does it do? • Burns the visceral fat • Keeps the heart muscle strong • Is fun!