March 22, 2018

Presenter:

James O. Hill, Ph.D.Professor Depts of Pediatrics & Medicine

University of Colorado School of Medicine

Moderator:James M. Rippe, MD – Leading cardiologist, Founder and Director;

Rippe Lifestyle Institute

Approved for 1 CPE (Level 2) by the Commission on Dietetic Registration, credentialing agency for the Academy of Nutrition and Dietetics.

NUTRI-BITES®Webinar Series

What's New in Obesity Treatment

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Today’s Faculty

James O. Hill, PhDProfessor Depts of Pediatrics & MedicineUniversity of Colorado School of Medicine

Moderator:James M. Rippe, MD – Leading cardiologist.Founder and Director, Rippe Lifestyle Institute

Learning Objectives To understand that current success in long-term treatment of

obesity is poor To identify reasons for poor success in long-term treatment of

obesity To review new approaches and new concepts that can be

incorporated into treatment programs to increase success To provide practical strategies that can be incorporated into

obesity treatment programs

NUTRI-BITES®Webinar SeriesWhat's New in Obesity Treatment

What’s New in Weight Management?

James O. Hill, Ph.D.Professor

Pediatrics & MedicineUniversity of Colorado School of Medicine

We have been seriously addressing obesity for 3 decades

How are we doing?

Overweight BMI >30 kg/m2

Obesity BMI >25 and 40 kg/m2

Note: Overweight is defined as BMI>=gender and weight-specific 95th percentile from the 2000 CDC Growth Charts. Source: National Health Examination Surveys II (ages 6-11) and III (ages 12-17), National Examination Surveys, I, II, III and 1999-204, NCHS, CDC.

Age 12-19

Age 6-11

Age 2-5

Trends in child and adolescent overweight

Chart1

1963-651963-651963-65

1971-741971-741971-74

1976-801976-801976-80

1988-941988-941988-94

1999-001999-001999-00

2001-022001-022001-02

2003-042003-042003-04

2005-062005-062005-06

2007-082007-082007-08

2009-102009-102009-10

2011-20122011-20122011-2012

Age 2-5

Age 6-11

Age 12-19

0.0419999994

0.0460000001

0.0500000007

0.0399999991

0.0610000007

0.0500000007

0.0649999976

0.0500000007

0.0719999969

0.112999998

0.1049999967

0.1030000001

0.1509999931

0.1480000019

0.1059999987

0.1630000025

0.1669999957

0.1389999986

0.1879999936

0.1469999999

0.1099999994

0.1509999931

0.1780000031

0.101

0.1959999949

0.1809999943

0.121

0.18

0.184

0.084

0.177

0.205

Sheet1

1963-651971-741976-801988-941999-002001-022003-042005-062007-082009-102011-2012

Age 2-50.05000000070.05000000070.07199999690.10300000010.10599999870.13899999860.10999999940.1010.1210.084

Age 6-110.04199999940.03999999910.06499999760.1129999980.15099999310.16300000250.18799999360.15099999310.19599999490.180.177

Age 12-190.04600000010.06100000070.05000000070.10499999670.14800000190.16699999570.14699999990.17800000310.18099999430.1840.205

Figure 5. Trends in obesity prevalence among adults aged 20 and over (age adjusted) and youth aged 2–19 years: United States, 1999–2000 through 2015–2016

Comparison of weight loss diets with different compositions of fat, protein and carbohydrates (n=811)

Sacks FS. et al. NEJM 2009;360(9) 859-873

WEIGHT LOSS

WEIGHT Re-GAIN

What we are doing is not working

PresenterPresentation NotesWt loss peaks at 6 months then gradual regain during interventionAverage weight loss 3-4 kg at end of 2 year interventionProbably guess what would happen once study ended.

Chart1

0000

6666

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24242424

65/15/20%

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45/15/40%

35/25/40%

months

weight loss (kg)

0

0

0

-5.7

-6

-5.7

-5.8

-5.3

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Sheet1

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65/15/20%-5.7-5.3-3.8-2.8

55/25/20%0-6-6-4.8-3.7

45/15/40%0-5.7-5.6-4.1-3

35/25/40%0-5.8-5.3-4.2-3.5

“If I had an hour to solve a problem, I would spend 55 minutes on understanding the problem and 5 minutes on the solution.”

We need to think about the problem in a new way

How to treat obesity

• Produce weight loss• Help people keep weight off forever

Height 5’7”Weight 400 lbsBMI 60

PrediabeticElevated BPElevated lipidsConstant joint pain

No friendsNo social lifeLow self-esteemDepressedVery Unhappy

What do you recommend for Jen?

• Surgery - 25-40% long-term success; regain in some; major life change

• Medications - ~7-10% most regained

• Devices - ~7-10% unclear• Lifestyle – 7-10% most regained

Treatment Options

Barriers to Success

• Focus on weight loss rather than weight loss maintenance• Diet confusion• Failure to appreciate human biology• Our goals are too low• Failure to understand the WHY• Failure to provide long-term support

The Energy Balance System

Energy Intake

Energy Expenditure

EnergyStores

Metabolic Regulation

Environmental FactorsBehavioral Factors• Food environment• Physical activity environment• Built environment• Social environment

• Amount and composition of food intake

• Amount and type of physical activity

• Sleep

Human Biology

But, my metabolism is broken

Start with human biology

Metabolic flexibility in physiological situations

Metabolic flexibility at the level of skeletal muscle and adipose tissue

Goodpaster B and Sparks LM Cell metabolism, 2017

Phenotypic flexibility

All peripheral organs have the ability to respond to metabolic challenge, and can contribute to the regulation of metabolic flexibility

Van Ommen B. Gens Nutr, 2014

Physical activity predicts metabolic flexibility

Bergouignan A et al. J Appl Physiol 2011;111:1201-1210

PresenterPresentation NotesPhysical activity predicts metabolic flexibility. This figure represents the relationship between the daily individual intraindividual variances of plasma insulin concentrations and nonprotein respiratory quotient (NPRQ). These variances have been measured before and after 2 standardized meals over a period of 7–10 h before and after an intervention reducing physical inactivity in healthy men and women. Physically active women (n = 8) were subjected to 2 mo of bed rest (cf Ref. 8), and trained men (n = 10) were asked to stop for 1 mo both structured and spontaneous physical activity (unpublished data). For an equivalent food quotient, metabolically flexible subjects will greatly increase carbohydrate oxidation (i.e., high variation in NPRQ; right) after the consumption of a meal despite a low increase in plasma insulin concentration (i.e., low variation in insulin; bottom). A metabolically inflexible individual, i.e., a person who also displays an insulin resistance, will displays a low increase in carbohydrate oxidation (i.e., low changes in NPRQ; left) despite an marked elevation in insulin secretion (i.e., high variation in insulin; top). We can observe that variances in NPRQ and insulin are linearly distributed along a continuum of physical activity level.

What is best way to get weight off?

• Any diet works as long as it creates negative energy balance• Exercise helps but you have to do a lot• Weight loss is time limited

Gardner et al. JAMA 2018

Average weight loss = 5.3 kg (5%)

Average weight loss at 1 year = 6 kg (6%)

Average weight loss = 5.3 kg (5%)

Foster et al. Ann Intern Med. 2010;153: 147-157.

Average weight loss at 1 year = 10.8 kg (10.4%)Average weight loss at 2 year = 7.4 kg (7.1%)

Average weight loss at 1 year = 10.9 kg (10.5%)Average weight loss at 2 year = 6.3 kg (6.1%)

Metabolic Changes with Weight Loss

• Energy expenditure declines• Compensatory changes in hormones/processes that facilitate fat storage• Hunger increases

The Energy GapBo

dy W

eigh

t

Time

energy gap

Pre-Weight Loss Metabolic Rate

Post-Weight Loss Metabolic Rate

• Food restriction• Exercise• Medications

PresenterPresentation NotesNO PERMISSION NEEDED

PresenterPresentation NotesHill JO, Peters JC, Wyatt HR. Using the energy gap to address obesity: a commentary. Journal of the American Dietetic Association. 2009 Nov;109(11):1848.

Figure 4

Environmental Factors Possibly Contributing to Obesity

Food is good tasting, convenient, inexpensive

It is easy to eliminate most physical activity from daily life

Comparison of weight loss diets with different compositions of fat, protein and carbohydrates (n=811)

Sacks FS. et al. NEJM 2009;360(9) 859-873

WEIGHT LOSS

WEIGHT Re-GAIN

PresenterPresentation NotesWt loss peaks at 6 months then gradual regain during interventionAverage weight loss 3-4 kg at end of 2 year interventionProbably guess what would happen once study ended.

Chart1

0000

6666

12121212

18181818

24242424

65/15/20%

55/25/20%

45/15/40%

35/25/40%

months

weight loss (kg)

0

0

0

-5.7

-6

-5.7

-5.8

-5.3

-6

-5.6

-5.3

-3.8

-4.8

-4.1

-4.2

-2.8

-3.7

-3

-3.5

Sheet1

06121824

65/15/20%-5.7-5.3-3.8-2.8

55/25/20%0-6-6-4.8-3.7

45/15/40%0-5.7-5.6-4.1-3

35/25/40%0-5.8-5.3-4.2-3.5

BiologyEnvironment

Behavior

Why is Weight Loss Maintenance Hard?

Optimize Metabolism

Body Weight

Energy Intake

Physical Activity Threshold for Optimal Weight Regulation

“Unregulated” Zone “Regulated” Zone

Adapted from Mayer et. al., 1956

Increase in physical activity

Modifying the Environment

• What factors would make a difference if modified?• What factors are modifiable?• Most changes oppose biology

- Eat less of foods that taste really good- Hard-wired to like sugar, fat, salt- move when you don’t have to move

1. Environmental change will be essential2. Not likely that we can modify the environment sufficiently that no cognitive

effort is needed

Swimming Upstream

BiologyEnvironment

Behavior

Why is Maintaining a Healthy Weight Hard?

Motivation

Only 2.7% of adults met criteria of 1) healthy diet; 2) adequate physical activity; 3) healthy weight; 4) non-smoking

-Loprinzi et al. Mayo Clinic Proc 2016

State of Slim: TRANSFORMATIVEWEIGHT MANAGEMENT

Stateofslim.com

Transformational Weight Management

Translating the Science: Development of State of Slim (SOS)

• National Weight Control Registry• Hill/Wyatt Research Program

DPPLook Ahead

• State of Slim• Extreme Weight Loss – reality show• Destination Boot Camp

SOS Based on >30 years of research

• >10,000 participants• Avg weight loss >70 lbs• Avg length of maintenance > 6 years• >25 publications• Identify common behaviors among those

most successful in weight loss maintenance

The National Weight Control Registry

What they do: Commonalities among NWCR participants in weight maintenance

• Low fat diet, attention to calories• Self-monitoring• Behavioral consistency• Dietary restraint• Breakfast• High levels of physical activity

ABC’S EXTREME WEIGHT LOSS

TransformationBIGGER THAN WEIGHT LOSS

47%

BehaviorMindset

Motivation

Transformation

What

Why

How

Lifestyle Changes (WHAT)

1. Fix metabolism- Exercise – about 1 hour/day- Sleep – may contribute; need more research

2. Get the weight off3. Fill energy gap

- Weight loss driven by caloric restriction- Maintenance – energy density; portion size; diet to match metabolism- Exercise –tweak from 60 min/day

Phases of State of Slim

• Phase 1 – get weight off – dramatic change (2 weeks)

• Phase 2- begin fixing metabolism (6 weeks)• Phase 3 – maintain activity while learning to eat

smart (8 weeks)• Each phase addresses what, why, and how

Motivation: Alignment of Purpose (WHY)

• Aligning your lifestyle with your purpose• Looking for connections between your life goals and your

lifestyle

PresenterPresentation NotesBring the picture of the woman straddling two rocks to this slide….bring those two together…the inner and outer selfYou won’t likely get there immediately. You wont likely be able to change everything at once. What matters is the intentionality and directionality of your life…always be looking for opportunities to live your purpose

What is Your Deeper Why? Let’s PEEL THE ONION

• Why do you want to lose weight? • Continue asking why until you get to the

person’s deeper life goals/purpose• Usually more emotional than logical

Changing Mindset (HOW)• What I get to do versus what I am giving up• Believing I have the power to change versus believing I am

a victim to my life/circumstances• Expecting success versus failure• Choosing your Hard - new lifestyle versus obesity • Developing emotional resiliency skills- bending versus

breaking in rougher times• Feeling fear and living in the arena • Change you physical and social environment• Writing your new story• Finding and aligning your new life with your purpose and

values• Creating your new identity - TRANSFORMATION

% o

f Gra

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eter

s (n

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)

0

5

10

15

20

25

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<0%

≥ 0

156 pounds lost

“I love my life. I love who have become. I love that I no longer get winded cleaning my house or walking up a flight of stairs; in fact I love just being able to run up a flight of stairsI love that I will just randomly start dancing or roll down a hill. I really love my calves (my lower legs that is). But I can’t say it enough, I LOVE LIFE!”

State of Slim Products

• 16 week transformation program• Year-long virtual program• Next steps• SOS Nation

Outcomes

XSOS

PresenterPresentation NotesWt loss peaks at 6 months then gradual regain during interventionAverage weight loss 3-4 kg at end of 2 year interventionProbably guess what would happen once study ended.

Chart1

00000

66666

1212121212

1818181818

2424242424

DBC

65/15/20%

55/25/20%

45/15/40%

35/25/40%

months

weight loss (%)

0

0

0

0

-5.7

-6

-5.7

-5.8

-5.3

-6

-5.6

-5.3

-18

-3.8

-4.8

-4.1

-4.2

-2.8

-3.7

-3

-3.5

Sheet1

06121824

65/15/20%-5.7-5.3-3.8-2.8

55/25/20%0-6-6-4.8-3.7

45/15/40%0-5.7-5.6-4.1-3

35/25/40%0-5.8-5.3-4.2-3.5

0-18

SOS NATION

The Maintain IT Model of Health Behavior Change and Maintenance (Health Psych Rev 2018)

Difficult to Change Health Behaviors

Executive Function

Inhibition

Working memory

Shifting

Centered Identity

Personal Values

Role-based identity

Δ

Group-based identity

Perceptual Lens

Behavior-based identity

Psychological well-being

Δ

HOW TO MEASURE SUCCESS

• I got my life back• I have more energy• I have better relationships• I have become the person on the outside I always was on

the inside• I lost weight

Transformation

Practical Advice• Fix the broken metabolism• Get the weight off• Provide lifestyle recommendations for keeping weight off• Pay attention to the why and how• Recognize that long-term support is required

We need more comprehensive weight management programs

• Financial models• Long-term engagement• Long-term outcomes• More than weight

What Happens If We Just Continue Doing What We Are

Doing?

“The definition of insanity is doing the same thing over and over again, but expecting different results.”

Albert Einstein

Stateofslim.comGet Involved

Our Transformation Team at the Anschutz Health and Wellness Center Thanks to ourfantastic faculty and staff!

Questions?

To understand that current success in long-term treatment of obesity is poor

To identify reasons for poor success in long-term treatment of obesity

To review new approaches and new concepts that can be incorporated into treatment programs to increase success

To provide practical strategies that can be incorporated into obesity treatment programs

NUTRI-BITES®Webinar SeriesWhat's New in Obesity Treatment

Based on this webinar the participant should be able to:

Conagra Nutrition Nutri-Bites®Webinar details

A link to obtain your Continuing Education Credit certificate will be will be available on our website and emailed within 2 days

Today’s webinar will be available to download within 2 days at: www.ConagraNutrition.com

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Recent CEU webinars archived at the Conagra Nutrition website: Exploring the Evidence on Dietary Patterns:

The Interplay of What We Eat and Health The Academy of Nutrition and Dietetics Evidence Analysis Library:

Leveraging This Resource to Maximize Your Efficacy Mediterranean Diet Pattern and Health

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John W. Erdman, PhDProfessor EmeritusUniversity of Illinois

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What's New in Obesity Treatment

�What's New in Obesity Treatment���will begin at the top of the hour�Audio for today’s presentation is being broadcast over your computer speakers, so be sure they are turned on and the volume is up�Today’s presentation in handout form can be �downloaded from: �http://bit.ly/handout-03-22-18 (type in your browser)March 22, 2018��Conagra Nutrition MissionWebinar logisticsToday’s FacultyLearning Objectives�What’s New in Weight Management?We have been seriously addressing obesity for 3 decades�Slide Number 9Slide Number 10Slide Number 11Comparison of weight loss diets with different compositions of fat, protein and carbohydrates (n=811)We need to think about the problem in a new wayHow to treat obesitySlide Number 15Slide Number 16Barriers to Success�The Energy Balance SystemBut, my metabolism is brokenSlide Number 20Slide Number 21Slide Number 22Slide Number 23What is best way to get weight off?Gardner et al. JAMA 2018Slide Number 26Metabolic Changes with Weight LossSlide Number 28Slide Number 29Environmental Factors Possibly Contributing to ObesityComparison of weight loss diets with different compositions of fat, protein and carbohydrates (n=811)Slide Number 32Slide Number 33Slide Number 34Slide Number 35Modifying the EnvironmentSlide Number 37State of Slim: TRANSFORMATIVE�WEIGHT MANAGEMENT�Stateofslim.com �Transformational Weight ManagementTranslating the Science: Development of State of Slim (SOS)The National Weight Control RegistryWhat they do: Commonalities among NWCR participants in weight maintenanceSlide Number 43Slide Number 44Slide Number 45Lifestyle Changes (WHAT)Phases of State of SlimSlide Number 48Motivation: Alignment of Purpose (WHY)What is Your Deeper Why? �Let’s PEEL THE ONIONChanging Mindset (HOW)Slide Number 52Slide Number 53Slide Number 54State of Slim ProductsOutcomesSOS NATIONThe Maintain IT Model of Health Behavior Change and Maintenance (Health Psych Rev 2018)�HOW TO MEASURE SUCCESSPractical AdviceWhat Happens If We Just Continue Doing What We Are Doing?Slide Number 62Slide Number 63Slide Number 64 Conagra Nutrition Nutri-Bites®�Webinar detailsSlide Number 68How are we doing?