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A Workshop Agenda and Abstracts Military Weight-Management Program Workshop State of the Art and Future Initiatives Subcommittee on Military Weight Management Committee on Military Nutrition Research Food and Nutrition Board Institute of Medicine The National Academies October 2~26, 1999 Monday October 25, 1999 9:00 Welcome on Behalf of the Food and Nutrition Board Dr. Allison A. Yates, Director, Food and Nutrition Board 9:05 Welcome on Behalf of the Subcommittee on Military Weight Manage- ment Dr. Richard Atkinson, Chair, Subcommittee 9:15 Opening Comments on Behalf of the Military LTC Karl E. Friedl, U.S. Army Medical Research and Materiel Com- mand, Fort Detrick, Frederick, MD 9:30 Important Historical Military Data: Obesity and Mortality Dr. William Page, Medical Follow-Up Agency, The National Acad- emies 179

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180 WEIGHT MANAGEMENT Part I: Weight Management in the Military Today (Moderator: Richard Atkinson) Panel: Current Military Policies and Approaches to Body-Weight Man- agement LCDR Sue Hite, Health and Physical Fitness Branch, USN LTC Francine LeDoux, Health Promotion Policy Officer, USA LTC Leon Pappa, Training Program Branch, USMC COL Esther Myers/LTC Regina Watson, Health Promotion, USAF Discussion l 1:00 Break 1 1:15 Challenges to Military Weight Standards and Maladaptive Practices of Service Members to Meet These Weight Standards MAJ Stephen Bowles, M.D., U.S. Army Soldier Support Institute, Ft. Jackson, SC 12:30 Lunch Part II: Current Military Weight-Loss/Management Programs (Moderator: John Vanderveen) 1:30 Panel: Effective Military Programs Air Force Weight-Management Program - LTC Joanne Spahn, Elmen- dorfAFB, Alaska The Air Force LEAN Program - CAPT Trisha Vorachek, McConnell AFB Impact of a Shipboard Weight-Control Program - Dr. Karen E. Dennis, Veterans Affairs Medical Center, University of MD School of Medicine Nutrition and Diet Aboard Submarines - LT Deborah White, Naval Submarine Medical Research Lab, Groton, CT The Army's LEAN Program: Current Update-LTC Larry James, Wal- ter Reed Army Medical Center Army Weight-Management Instruction to Master Fitness Trainers - Dr. Lou Tomasi, LT Kerryn Davidson, Army Physical Fitness School, Ft. Benning, GA Discussion 3:45 Break

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APPENDIXA 181 Part III. Factors Affecting Weight Management (Moderator: John Fern- strom) 4:00 Behavior Dr. Patrick O 'Neil, Medical University of South Carolina Dr. Gary Foster, University of Pennsylvania Discussion Adjourn Tuesdav. October 26. 1999 Part III. Factors Affecting Weight Management (cont.) (Moderator: Wil- liam Dietz) 9:00 Genetic Influences on Obesity Dr. Anthony Com?=zi, Southwestern Foundation for Biomedical Re- search Effects of Age, Gender, and Ethnicity on Ideal Weight Dr. June Stevens, University of North Carolina - Chapel Hill Discussion 1 0:30 Break Pharmacological Aids (Moderator: Steven Heymsfield) 11:00 The Pharmacology of Weight Loss and Its Potential Application in the Military Setting MAJH. Glenn Ram os, M.D., Fort Gordon, GA Use of Pharmacologic Aids in Weight Management Dr. Frank Greenway, Pe,~nington Biomedical Research Center Discussion 12:00 Lunch Physiology - Physical Activity (Moderator: Barbara Hansen) 1:00 Effects of Exercise, Diet, and Weight Loss on Lipid Metabolism Dr. Marcia Stefanick, Stanford University Reproductive Health Issues in Fitness and Weight-Control Programs Dr. Anne Loucks, Ohio University

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182 2:00 Obesity: An Infectious Disease? Dr. Nikhil Dhurandhar, Waryne State University Discussion WEIGHT AL4NAGEMENT Part IV: Factors Affecting Long-Term Maintenance of Weight Loss (Mod- erator: Arthur Frank) Dr. George Blackb urn, Harvard Medical School Dr. John Jakicic' Miriam Hospital and Brown University Discussion Break Part V: Effective Strategies for the Military Setting (Moderator: Gail Butterfield) 4:00 Panel Discussion Military Speakers: CAPT Trisha Vorachek (USAF) LT Deb orah White (USE Dr. H. Glenn Ram os LISA) LTKerryn Davidson (USAJ Civilian Speakers: Dr. Frank Greenway Dr. John Jakicic Dr. Patrick O 'Neil Summary of the Workshop Dr. Richard Atkinson, Subcommittee Chair Dr. John Vanderveen, Vice-Chair Adjourn

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APPENDIXA 183 WORKSHOP ABSTRACTS THE ARMY WEIGHT CONTROL PROGRAM (AR 600-9) LTC Francince M. LeDoux, Health Promotion Policy Off cer The primary objective of the Army Weight Control Program (AWCP) is to ensure that all personnel are able to meet the physical demands of their duties under combat conditions and to present a trim military appearance at all times. Proper weight control assists Army personnel in establishing and maintaining discipline, operational readiness, optimal physical readiness, and effectiveness. The regulation establishes appropriate body-fat standards and provides proce- dures by which personnel are counseled to assist them in meeting the prescribed standards. Historical Perspective Prior to 1981, height/weight tables and a physician's assessment were used to determine body-fat standards. In 1981 DOD implemented the Physical Fitness and Weight Control Program (DOD Directive 1308.19. This program stated that various tests were acceptable for use in determining body fat. Between 1983 and 1986, the Army used the "pinch test" to determine body fat. Beginning in 1987, the DOD revised Directive 1308.1 stating that the skinfold measurement test would no longer be used, and that only the "Tape" measurement method should be used to measure body fat. The Army Weight Control Program (U.S. Army, 1986) was published in 1986. In 1994, Interim Change 101 specified that all soldiers were to be issued Handbook/Issue 15. In 1995, DOD Directive 1308.1 was revised, changing the body-fat standards and establishing fat standards for pregnant soldiers (DOD, 1995~. Rationale The AWCP is based on body composition (body fat vs. total body mass). Physical fitness is key to body composition. Fit soldiers are better able to carry their load. They have less body fat and more muscle mass. In contrast, overfat soldiers are: less able to perform physical tasks, are at greater risk of developing injury, and have lower Army Physical Fitness Test scores. Excessive body fat also detracts from soldierly appearance. Key Requirements Soldiers are weighed every 6 months. If a soldier is overweight (exceeds the weight-for-height standard) he or she will be measured for percent body fat us-

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184 WEIGHT MANAGEMENT ing the "tape test" circumference method. The measurement sites for males are: abdomen, neck with a range of 20-26 percent body fat (maximum); and for fe- males: neck, forearm, wrist, and hip with a range of 20-36 percent body fat (maximum). If a soldier is overfat he or she is enrolled in the AWCP. AWCP Enrollment Soldiers enrolled in the AWCP will have a permanent record on file. Each soldier enrolled is required to attend nutritional counseling and is weighed on a monthly basis. A soldier may only be removed from the program when body-fat standards have been achieved. The height/weight table standards will not be used. The standard requires a loss of 3-8 lb per month. If a soldier fails to make satisfactory progress in two consecutive months, he or she can be discharged per AR 635-200, Chapter 18, Personnel Separations (U.S. Army, 2000~. Medical Limitations and Pregnant Soldiers Medical limitations include pregnancy, hospitalization, prolonged medical treatment, and positive profiles according to Mandatory Medical Review Boards. Once a female soldier is diagnosed as pregnant, she is exempt from the standards of AR 600-9 during pregnancy and for 6 months postpartum. The sol- dier will remain in the program if she was enrolled previously. After 6 months postpartum, she will continue on the AWCP with physician clearance. Postpar- tum soldiers may request to be weighed anytime before 6 months. This standard implements DOD Directive 1308.1, July 20, 1995. References DOD (U.S. Department of Defense). 1995. DOD Physical Fitness and Body Fat Program Procedures. Department of Defense Directive 1308.1. July 20. Washington, DC: U.S. Government Printing Office. U.S. Army. 1986. The Army Weight Control Program. Army Regulation 600-9. September 1. Washington, DC: U.S. Government Printing Office. U.S. Army (U.S. Department of the Army). 2000. Enlisted Personnel. Army Regulation 635-200. November 1. Washington, DC: U.S. Government Printing Office.

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APPENDIXA CHALLENGES TO MILITARY WEIGHT STANDARDS AND MALADAPTIVE PRACTICES OF SERVICE MEMBERS TO MEET THESE WEIGHT STANDARDS MAJ Stephen V. Bowles, PhD, United States Army Soldier Support Institute, Director, USAREC Command Psychological Operations, Fort Jackson, South Carolina 185 At the time this abstract was written, no information on service members who exceed weight standards or have been discharged from the service in 1999 could be obtained from DOD or individual services. It has been reported that as many as 40 percent of the soldiers discharged from the Army was due to service members being overweight (James et al., 1997~. The military faces several challenges to include: overweight accessions into the military, lifestyle practices of overweight service members, and command awareness of lifestyle change programs. Challenges to Military Weight Standards With current recruitment shortfalls, the number of overweight recruits (meeting accession standards but not the services retention standard for weight) may be increasing due to a smaller applicant pool. This can translate into a considerable number of overweight personnel entering yearly that meet accession standards but do not meet military retention standards at that time. This may place extra strain on the system to get personnel physically fit, while preparing new service members for the complexities of the military. In addition, this also places increased stress on young service members who are in many cases away from home for the first time in their first job. With this in mind, educating recruiters on healthy lifestyle changes for new recruits may be beneficial. This may help reduce the time spent on new overweight service members and retain more personnel. Recruiters can be provided with lifestyle change training in recruiting school and provide recruits with approaches to healthy lifestyle change. Similarly, military academies and ROTC programs can provide training to new officers throughout their school years. Students must be trained in maintaining healthy lifestyles in accordance with military weight guidelines. These are important preventative measures in stressful academic environments, which may preclude students from engaging in maladaptive eating behaviors. Eating on the run is sometimes dictated by our mission. When training new service members today we have attempted to offer adequate time to eat in dinning, facilities. This is different from the past where older, overweight service members have identified early dining experiences as eating as much as they can in as little time as possible. This set the pattern of their eating over the course of

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186 WEIGHT A~4NAGEMENT their military careers. When providing new personnel training and education on healthy lifestyle behaviors, we must incorporate these changes into our training structures as best we can. As a tradition, service members have complained about the food provided to them in the mess hall or galley. However, great improvements have been made in the quality of foods. More effort needs to be initiated in educating cooks (James et al., 1999) to provide more variety in the low-fat main dishes served for lunch and dinner. Furthermore, there should be uniformity across dining facilities in the education of customers on calorie and fat gram amounts per food served. Maladaptive Practices of Service Members While there are differences in each of the services' military weight/body-fat standards, the goal of each service member twice a year is to meet the weight standard and pass the physical fitness test. The family is well aware of the borderline or overweight service member's plight at these times of the year. There is often tension in the home emanating from the service member's desire and actions to stay off the weight program. This may involve physical fitness training five times or more a week. Additionally, a service member will attempt to lose weight by using over-the-counter medication. They may go to the local health food store and purchase different herbal supplements or attend a local weight-reduction clinic and get on prescription medication. They will sit in the sauna, or they may obtain laxatives through the local drug store or their medical facility if they are on the hospital staff. If they are looking for the more popular diets, they can choose from protein, blood, cabbage, grapefruit or what ever the most recent diet is. Of the 108 applicant records examined for the Eisenhower LIFE Program, 34 percent reported starving or fasting, 33 percent reported using laxatives or over-the-counter medication, and 4 percent reported purging at some time in their career. Meeting Military Weight Standards: Lifestyle Change Programs Across the services there is a need to become more familiar with various programs available in local areas and encourage the use of these programs. Units that have used local lifestyle change (weight) programs are able to save financial resources for their organizations and save units time if their armed service program is several hours or states away from where they are located. As a group, the medical field must educate the commanders in their area on services available to assist service members in weight reduction. Commanders, after seeing the results of their service members in lifestyle change programs, will be a steady referral source to programs. The Eisenhower LIFE Program (a week-long day-treatment program and 1 year follow-up) disseminated an 11

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APPENDIX A 187 question survey asking commanders and supervisors for their feedback on the program. The results of 9 of the questions from the survey are found in Figure 1. Ninety percent of the respondents were from the Army, while the remainder of the respondents were Mom the Air Force, Navy, and Marines. The results of the survey indicate that 22 out of 24 commanders/ supervisors responding, were satisfied with the program. Most respondents agreed that the program saved their unit time (81 percent), prevented the service member from separation from the military (91 percent), taught the service member new information for weight management (96 percent), and provided a comprehensive multidisciplinary program for weight reduction (91 percent). In addition, 96 percent believed a specialized physical training program is helpful for weight reduction, while 86 percent supported a specialized LIFE physical training program. While 95 percent believed weekly support groups are helpful, only 73 percent supported service members attending weekly support groups. Though some commanders/supervisors prefer to operate their own physical training and follow-up support (perhaps due to unit esprit de corps or due to shortage of work personnel), these results suggest that overall, commanders support this lifestyle change program. - Supporrt Weeldy meetngs Believe in v~eeldy support groups Support Specialized UFE PT 1 Provided Comp. Multi-disciplinary Sepcialized Pt Program Satistaction program Taught New Irdo Prevented Separation Saving Unit Time l 1 1 0 10 20 30 40 50 60 70 80 90 100 Percentage FIGURE 1 Command Satisfaction Survey. l

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188 WEIGHT MANAGEMENT These findings suggest that commands are open to assistance from weight- reduction programs to maintain readiness levels in their organizations. Similar education and training can be provided across the services to assist service members in meeting their organizations' weight standards. The training pro- vided to service members and in support of service members can be provided through healthy lifestyle change programs. References James LC, Folen RA, Garland EN, Edwards C, Noce M, Gohdes D, Williams D, Bowles S. Kellar MA, Supplee E. 1997. The Tripler Army Medical Center LEAN program: A healthy lifestyle model for the treatment of obesity. Mil Med 162:328-332. James LC, Folen RA, Page H. Noce M, Brown J. Britton C. 1999. The Tripler LEAN program: A two-year follow-up report. Mil Med 164:389-395. THE SENSIBLE WEIGH LIFESTYLE CHANGE PROGRAM: AN AIR FORCE WEIGHT- MANAGEMENT PROGRAM Joanne M. Spahn, Lt Col' USAF, BSC, MS, RD The health risks associated with overweight and obesity are well established (NHLBI, 1998; Van Itallie, 1985) end the incidence of overweight continues to rise (Kuczmarski et al., 1994~. In the military, sustained overweight can end an otherwise successful career. An increased operations tempo, decreased physical activity, and easy availability of calorie-dense foods may frustrate earnest weight-management efforts. Until the 1990s, the typical Air Force treatment program for overweight entailed a single group class where military members were given instruction on a low calorie diet, typically 1,200-1,800 calories, information on behavior modification, and counseled to exercise three to five times a week for 30 minutes. In the late 1980s and early 1990s, numerous published or home-grown multisession programs were established at a variety of sites. These programs for the most part emphasized increased physical activity, modest calorie restriction, skill development in selecting and preparing healthy foods, and behavior modification techniques. At most sites, these programs could accommodate few participants. There was fear among active duty person- nel that weight loss would be too slow to meet weight-loss requirements. In the early 1990s, the National Institutes of Health held a Technology Assessment Conference on Methods for Voluntary Weight Loss and Control. In 1995, Weighing the Options: Criteria for Evaluating Weight-Management Programs was published (IOM, 1995~. These materials were utilized to guide development of The Sensible Weigh Program initiated in 1997. Practical

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APPENDIXA 189 managerial constraints and Weight Management Program (WMP) guidelines factored into program development. Specifically, this included the need for military members to loss 3 to 5 lb the first month identified as overweight to avoid disciplinary action and the need for Wing and Army Commander support of treatment incorporating increased use of duty time. Deployment of The Sensible Weigh to a large number of bases with varying levels of manpower support has also shaped program implementation across the Air Force. The Sensible Weigh is a lifestyle change program aimed at optimizing weight and fitness of military members and their families. It is a science-based protocol designed to prevent weight gain, facilitate weight loss, and the maintenance of weight loss. It was developed to support the Air Force WMP and as an avenue for commanders and health care providers to intervene with concerned individuals early, before negative consequences occur. This multi- disciplinary program offers participants a variety of strategies from which to choose to improve their nutrition, fitness, and health. Program materials are available on the web at the following site: http://aimam.satx.disa.mil. Clients enrolling in The Sensible Weigh can either self-refer, be sent by their squadron, or be referred by a medical provider. The protocol begins with a thorough assessment of anthropometric, biochemical parameters, comorbidities, medications, family history, weight and dieting history, exercise habits, diet readiness, and evaluation of the Physical Activity Readiness Questionnaire. Nursing personnel review the assessment form with clients and use standardized guidelines to refer clients to medical providers when the need arises. Assessment data is used to tailor the program to meet client needs, discuss the benefits of weight management in terms other than pounds lost, and to facilitate measure- ment of program efficacy. Program length varies from 4 to 12 weeks. The first four core classes are taken by all participants in The Sensible Weigh and provide a foundation of information and skills. The first class orients clients to the concept of lifestyle change, the diverse benefits of weight management, addresses relapse preven- tion and diet readiness, and encourages increased physical activity. Clients are instructed on how to complete a food and exercise diary and are required to monitor their eating habits for the coming week. This is an important class for establishing rapport, venting anger, and building a trusting relationship. This was a difficult class to implement because of the immediate penalties incurred if members did not lose the prescribed weight in the first 30 days. Members and supervisors were concerned that the member did not "get the diet." During the second class, each client receives a calorie and fat budget following Step I diet recommendations. Clients are offered a variety of strategies from which to choose to modify their diet. Strategies include calorie counting, fat gram counting, following food guide pyramid guidelines, and following a calorie controlled meal plan. Pros and cons of each method are discussed and clients select the strategy they feel best meets their needs. The food and exercise

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230 WEIGHT MANAGEMENT The fast-food market has increasingly become a staple of American food culture over the years. Effective marketing strategies coupled with broader, inexpensive choices have made this industry a prime culprit in the American obesity epidemic. Unfortunately, with the increase in variety, palatability, convenience, and availability of food, there has also been a decline in the amount of exercise performed by the average American. Sedentary desk jobs, computers, fewer safe places for exercise, and more elevators and drive-through restaurants are only a few of the contributors to this escalating problem. With the changing environment and the discouraging rates of weight regain, it is imperative that we take a closer look at long-term weight maintenance and the various methods successful maintainers utilize to prevent weight gain. To get a better perspective in this area, it is appropriate to review a portion of the long- term data provided by the National Weight Control Registry (NWCR). The NWCR is a registry of individuals who have been followed in a prospective manner having been successful at maintaining significant weight losses. Partici- pants in the NWCR have lost, on average, more than 65 pounds and maintained their weight losses for 5.7 years (McGuire et al., l999b). Long-term studies of weight loss in individuals participating in the NWCR indicate that those who regain weight typically show a demonstrated decline in self-monitoring. This includes techniques such as frequent self-weighing as well as keeping food and exercise diaries. These individuals showed a marked decrease in physical activ- ity of more than 800 calories per week, coupled with increases in the percentage of calories taken in from fat. The study also showed the re-gainers to have a higher lifetime level of intentional weight cycling (McGuire et al., l999b). Those who regained weight were more likely to have sought assistance for weight loss rather than utilizing self-directed weight loss methods, and were more likely to have used a liquid formula diets for their initial weight loss. In comparison, it has been shown that 72 percent of successful weight losers lost weight on their own, 20 percent used commercial weight-loss programs, and 5 percent utilized a university-based program (McGuire et al., 1998~. Those who gained weight also were shown to have been heavier at their maximum weight, initially lost a greater percentage of their maximum weight (> 30 percent) and had maintained their weight loss for fewer years than maintainers (McGuire et al., l999b). What predicts successful weight maintenance? Research has shown the five most common links appear to be (1) physical activity, (2) self-monitoring, (3) problem solving, (4) continued contact, and (5) stress management (Foreyt, 1 9991. Physical Activity Longitudinal studies with 2-10 years of follow-up results have observed that physical activity is related to less weight gain over time (NHLBI, 19981. It

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APPENDIXA 231 is a well-known fact that physical activity is a good predictor of weight mainte- nance (Foreyt, 1999~. A review of successful weight maintainers reveals that they engaged in more strenuous activities such as running, weight lifting and aerobics than regainers, and participated in more activities that made them sweat (McGuire et al., 1999a). Specifically, 52 percent of maintainers reported engag- ing in three or more episodes that made them sweat in a typical 7-day week compared with 32-36 percent of the regainers and controls (McGuire et al., 1999a). Although, it is important to note it has been demonstrated that both gainers and maintainers reported decreases in total calories expended thorough physical activity. However, maintainers reported a decrease of only 500 calories per week where gainers reported a decrease of almost 1,000 calories per week at 1-year follow-up (McGuire et al., l999b). Self-Mon~toring Self-monitoring is the cornerstone of behavioral treatment (Foreyt, 1999~. One of the common findings observed in individuals who are successful at long- term weight loss is that maintainers report extensive use of behavioral strategies for reduction in dietary fat intake, self weighing, and physical activity (McGuire et al., 1 999a). Taking a closer look at self weighing as a form of self-monitoring, it has been shown that 55 percent of maintainers reported weighing themselves at least once each week, where only 35 percent of the regainers reported weigh- ing themselves frequently (McGuire et al., 1 999a). Other forms of self- monitoring, such as keeping a food or exercise record, functions to assist the patient in assessing overall intake of various foods in relation to the amount of exercise performed. Despite the fact that caloric intake may be underestimated, the records sensitize patients to the eating and exercise portion of their lifestyle (Blackburn and Kanders, 1994~. Problem Solving Generally, it has been shown that those individuals who confront life's stressors with a positive problem-solving attitude are more likely to have greater success in any endeavor (Foreyt, 1999~. All aspects of effective obesity treat- ment involve improved problem solving and confrontational skills. A survey of weight maintainers showed that 95 percent of them utilized problem solving or confrontational technique. In comparison, only 10 percent of those who relapsed used problem solving skills and instead, tended to use escape-avoidance ways of coping with stress, such as eating, smoking, or taking tranquilizers (Blackburn and Kanders, 1994~. These findings support the theory that once an individual makes a behavioral change, relapse occurs in the face of insufficient coping skills (Blackburn and Kanders, 1994~.

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232 Continued Contact WEIGHT MANAGEMENT Frequent patient-provider contact is associated with the best maintenance of weight loss (Anderson and Wadden, 1999~. This contact does not have to be given solely by the physician, but by a registered dietitian, nurse, or office staff. Contact can be made to patients, via phone, fax, or email. These continued visits have been shown to enhance motivation, troubleshooting, and teach patients a new set of skills. Overall, the longer patients remain in behavioral treatment the longer they are expected to maintain their weight loss (Anderson and Wadden, 1 999). Stress Management Literature has shown that stress has a facilitating effect on the eating behav- ior of individuals most likely to be patients in a weight-loss program (Blackburn and Kanders, 1994~. This excessive stress appears to predict early drop out from organized weight-loss programs (Foreyt, 1999~. It is essential to help patients identify a strategy when confronted with stressful events to allow them to gain quick composure in order to use other behavioral techniques (Blackburn and Kanders, 1994~. Working with patients to help address and alleviate the stress- eating relationship in weight-loss treatment and maintenance is of key impor- tance (Foreyt, 1999~. Four basic stress management procedures used in weight maintenance include self-monitoring, environmental control, relaxation training, and contingent relaxation (Blackbum and Kanders, 1994~. Conclusion Regardless of the weight-loss option selected, patients should strive to develop the skills that have been reported by successful weight-loss maintainers. These techniques include exercising regularly, monitoring weight frequently, eating a low-fat diet, recording food intake, and developing effective problem solving skills (Anderson and Wadden, 1999~. In addition, believing in yourself (Fletcher, 1994) and not relying on willpower can help your patients achieve success in their weight-maintenance endeavors. References Anderson DA, Wadden TA. 1999. Treating the obese patient. Suggestions for primary care practice. Arch Family Med 8:15~167. Blackburn GL, Kanders BS. 1994. Obesity: Pathophysiology, Psychology and Treatment. New York: Chapman and Hall. Fletcher AM. 1994. Thin for Life. 10 Keys to Success from People Who have Lost Weight and Kept it Off: Shelburne, VT: Chapters Publishing.

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APPENDIXA 233 Foreyt JP. 1999 (July). Strategies for Maintenance and Relapse Prevention. Ab- stract and slides presented at the Harvard Obesity Conference. McGuire MT, Wing RR, Klem ML, Hill JO. 1999a. Behavioral strategies of individuals who have maintained long-term weight losses. Obes Res 7:334- 341. McGuire MT, Wing RR, Klem ML, Lang W. Hill JO. l999b.What predicts weight regain in a group of successful weight losers? J Consult Clin Psy- chol 67:177-185. McGuire MT, Wing RR, Klem ML, Seagle HM, Hill JO. 1998. Long-term maintenance of weight loss: Do people who lose weight through various weight loss methods use different behaviors to maintain their weight? Int J Obes 22:572-577. NHLBI (National Heart, Lung and Blood Institute). 1998. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: The evidence report. Obes Res 6:5 lS-209S. Rippe JM, Crossley S. Ringer R. 1998. Obesity as a chronic disease: Modern medical and lifestyle management. JAm Diet Assoc 98:S9-S15. Shick SM, Wing RR, Klem ML, McGuire MT, Hill JO, Seagle H. 1998. Persons successful at long term weight loss and maintenance continue to consume a low energy, low fat diet. JAm Diet Assoc 98:408~13. Williamson DF, Derdula MK, Serdula MK, Anda RF, Levy A, Byers T. 1992. Weight loss attempts in adults: Goal, duration and rate of weight loss. Am J Public Health 82:1251-1257. FACTORS AFFECTING LONG-TERM MAINTENANCE OF WEIGHT LOSS AND WEIGHT REGAIN John M. Jakicic, PhD, Assistant Professor, Brown University School of Medi- cine, Miriam Hospital Weight Control and Diabetes Research Center Obesity is a significant health problem in the United States, and it is estimated that in excess of 50 percent of adults are considered overweight (BMI > 25 kg/m2~. Despite documented short-term success in weight-loss programs, it has been shown that typically, one-third of weight lost will be regained within 1-3 years, with total regain occurring within 3-5 years. Therefore, it is important to examine the most effective implementation of strategies that have been shown to maximize long-term weight loss and prevent weight regain. Despite the belief that most individuals are unsuccessful at long-term weight loss, the National Weight Control Registry (NWCR) has identified a large number of individuals that have successfully maintained at least a 30-lb weight loss for a minimum of 1 year (Klem et al., 1997~. Close examination of this data set shows that there are individuals that have maintained a weight loss of approximately 60 lb and have maintained this for 5.6 ~ 6.8 years. Therefore,

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234 WEIGHT M4NAGEMENT results from this study should be examined closely to determine if there are unique strategies that can be used to enhance long-term weight loss in over- weight adults. Exercise An interesting finding in the NWCR is that individuals continue to participate in strategies to maintain both healthful eating and exercise behaviors. However, a unique finding in these data is that these individuals are maintaining extremely high levels of exercise, with leisure-time activity being 2,000 to 2,500 kcal/week for both men and women (Klem et al., 1997~. This value is much greater than the current public health recommendation for physical activity to improve health (HHS, 1996; Pate et al., 1998~. However, this level is similar to the amount of activity shown by Schoeller and colleagues (1997) to minimize weight regain in overweight women, and this amount of activity was verified using doubly labeled water. Jakicic and colleagues (1999) have shown that when combined with dietary modification, weight regain in the 12 months following was minimized when exercise exceeded 150 minutes per week. However, of interest is that there was no weight regain in women exercising greater than 200 minutes per week throughout the entire 18 months of treatment. Thus, overall, these results appear to verify the conclusion of Pronk and Wing (1994) based on a review of the literature, that physical activity is one of the best predictors of long-term weight maintenance. Despite the evidence presented above, debate remains regarding the optimal intensity of the activity that will enhance long-term weight loss and minimize weight regain. In a 20-week study of overweight women, Duncan and colleagues (1991) showed that total energy expenditure rather than exercise intensity is the key factor for regulating body weight. However, data from the NWCR suggests that individuals successful at long-term weight loss participate in a high level of vigorous intensity activity (Klem et al., 1997~. Despite these findings, the results of this study are cross-sectional and have not been confirmed by a randomized clinical trial. Currently, Jakicic and colleagues are conducting a randomized clinical trial to examine the dose-response of exercise (intensity and energy expenditure) on weight loss across a 24-month period of time. Despite the debate over the optimal amount of activity that is necessary to maximize long-term weight loss, little debate exists as to the importance of physical activity for overweight adults. Data from the Center for Aerobics Research at the Cooper Institute have shown that physical fitness can have a significant impact on mortality rates independent of body weight. Lee and colleagues (1998) have shown that there is a significant reduction in mortality rates in overweight adults that also have higher levels of physical fitness, and this mortality rate is similar to leaner unfit adults. These results suggest that

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APPENDIXA 235 interventions that improve physical fitness in overweight adults can have significant health benefits independent of changes in body weight. Therefore, it is important to develop and implement strategies to increase exercise participa- tion in overweight adults. Recently, Dunn and colleagues (1999) have shown that a home-based lifestyle activity intervention cart be as effective over 18-24 months as a structured clinic-based exercise intervention. In addition, in studies of over- weight women, Jakicic and colleagues (1995, 1999) have shown that multiple short bouts of exercise can be effective in previously sedentary individuals. Therefore these strategies should be considered when implementing inter- ventions to address body-weight regulation within the military. Changes in the Micro and Macro Environments It has been suggested that we live in a "toxic environment" relative to factors that affect body weight. There are a number of factors, such as accessibility of high fat/calorie foods and labor saving devices that affect our eating and exercise behaviors. However, it has been shown that the environment can be manipulated to have a positive impact on eating and exercise behaviors. For example, French and colleagues (1997) showed that lowering prices in vending machines for low-fat snacks increased the amount of low-fat snacks that were purchased. In addition, Andersen and colleagues (1998) have reported that posting signs to encourage the use of stairs in a shopping mall can have a positive impact on activity patterns. It may also be important to increase access to healthier foods and provide opportunities for physical activity, and this can be done to both the macro and micro environments. For example, Sallis and colleagues (1990) showed that individuals living in close proximity to exercise facilities were more active than those living further away from these facilities. Jakicic and colleagues (1997) showed that there was a significant correlation between physical activity and having home-exercise equipment. More recently, Jakicic and colleagues (1999) reported that providing overweight adults with home treadmills increased exercise participation. Therefore, these findings suggests that modifications to the environment may have a positive impact on health behaviors related to body- weight regulation. Long-Term Changes in Dietary Intake Despite the fact that exercise appears to be one of the best predictors of long-term weight loss, the impact of eating behaviors on this process should not be overlooked. It has been shown in short-term studies that exercise alone has little impact on body weight when compared with diet or the combination of diet plus exercise (Wing et al., 1998~. Moreover, the effectiveness of exercise in

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236 WEIGHT MANAGEMENT long-term weight loss may be partially explained by its link to healthful eating behaviors. For example, Klem and colleagues (1997) reported that individuals successful at long-term weight loss maintained healthfi~1 eating behaviors along with high levels of exercise. Unpublished data from a study conducted in our laboratory has shown that individuals that have maintained high levels of exercise also report maintaining more healthful eating behaviors than those not maintaining their exercise over a period of 18 months. Thus, these results appear to suggest that both dietary and exercise behaviors should be targeted to enhance long-term weight loss and to prevent weight regain. Continued Contact It has been suggested that obesity is a chronic disease and should be treated with a chronic disease intervention. Perri and colleagues (1987) have shown that maintaining contact with a weight-loss program long-term enhances weight loss. However, from a clinical perspective, it becomes difficult to keep individuals in treatment programs for long periods of time. Thus, the typical model of providing group sessions during the maintenance phase of treatment may not be appealing to individuals participating in these programs. Therefore, maintaining contact through other means may prove to be more effective in long-term intervention programs. Some of the strategies that have been shown to be successful are telephone contacts and mailings. In addition, interventions using social support strategies and computers are currently ongoing. Therefore, these intervention strategies may be appealing to the military when attempting to deliver interventions to soldiers that may be deployed throughout the world. Targeting High Risk Periods for Weight Gain There is some evidence that there are specific periods when individuals may be at risk for weight gain, and this may be an important factor for the military to consider. One period of time is during early adulthood, and weight gain is typically accompanied by a trend for decreases in physical activity. For example, unpublished data from our laboratory has shown that college-aged men and women participating in regular exercise gained less weight during their college years than those not regularly participating in exercise. Weight gain may also occur in individuals that are already moderately overweight. We have shown that moderately overweight adult men left untreated will gain a significant amount of weight over a period of 16 weeks, whereas participation in a program to modify exercise behaviors and minimize fat intake appears to have a beneficial effect on body weight in these individuals (Leermakers et al., 1998~. Therefore, it may be important for the military to identify individuals that are moderately overweight and encourage changes in exercise and eating behaviors to prevent further weight gain.

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APPENDIX A 237 The postpartum period may be an extremely important time for women with regard to body-weight regulation, and interventions targeting this period may be extremely important. For example, in a study of women following pregnancy, women left untreated lost 4.9 kg with 11.5 percent returning to prepregnancy weight, whereas those participating in a correspondence-based treatment pro- gram lost 7.8 kg and 33 percent returned to prepregnancy weight (Leermakers et al., 1998~. Therefore, it may be important for the military to consider offering postpartum interventions to minimize the retention of body weight in women during this period. Application to Weight-Regulation Initiatives in the Military There may be some debate in the various branches of the military regarding acceptable body-weight values and methods of measuring these parameters. However, regardless of the absolute value that is determined to be acceptable, it should be recognized that there are soldiers in the military that are at risk for weight gain. Therefore, the military should consider implementing strategies that may minimize weight gain in these individuals, and these could include changes in the environment and providing access to programs related to eating and exercise behaviors. In addition, the military should consider implementing interventions early on (i.e., basic training) that will permit soldiers to transfer their activity and eating behavior outside of a controlled environment setting. For example, when an individual enters the military, it is commonly believed that they are in an environment in which they have little control over their eating and exercise behaviors, and these factors are controlled by the military. However, soon after that period of time, soldiers have more freedom of choice, and this is a period when they could potentially relapse into typical behavioral patterns. Thus, providing opportunities for soldiers to maintain their newly developed exercise and eating behaviors may minimize body weight-regulation concerns in this population. Moreover, one factor that should be considered is the history of the soldier prior to entering the military. It is likely in some cases that an individual lost weight just prior to entering the military in order to conform to the military standards and to be accepted into the military. However, the period following this initial weight loss is a high-risk time for weight regain. Identifying individuals that meet these criteria, and targeting interventions at this group of individuals may prove to be beneficial in preventing relapse while in the military.

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238 WEIGHT MANAGEMENT References Andersen RE, Franckowiak SC, Snyder J. Bartlett SJ, Fontaine KR. 1998. Can inexpensive signs encourage the use of stairs? Results from a community intervention. Ann Intern Med 129:363-369. Duncan JJ, Gordon NF, Scott CB. 1991. Women walking for health and fitness: How much is enough? JAm Med Assoc 266:3295-3299. Dunn AL, Marcus BH, Kampert JB, Garcia ME, Kohl III HW, Blair SN. 1999. Comparison of lifestyle and structured interventions to increase physical ac- tivity and cardiorespiratory fitness. JAm Med Assoc 281 :327-334. French SA, Jeffery RW, Story M, Hannan P. Snyder MP. 1997. A pricing strat- egy to promote low-fat snack choices through vending machines. Am JPub- lic Health 87:849-851. HHS (U.S. Department of Health and Human Services). 1996. Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention and National Center for Chronic Disease Prevention and Health Promotion. Jakicic JM, Wing RR, Butler BA, Jeffery RW. 1997. The relationship between the presence of exercise equipment and participation in physical activity. Am J. Health Promot 11:363-365. Jakicic JM, Wing RR, Butler BA, Robertson RJ. 1995. Prescribing exercise in multiple short bouts versus one continuous bout: Effects on adherence, car- diorespiratory fitness, and weight loss in overweight women. Int J Obes 19: 893-901. Jakicic JM, Winters C, Lang W. Wing RR. 1999. Effects of intermittent exercise and use of home exercise equipment on a&erence, weight loss, and fitness in overweight women. JAm Med Assoc 282: 155~1560. Klem ML, Wing RR, McGuire MT, Seagle HM, Hill JO. 1997. A descriptive study of individuals successful at long-term maintenance of substantial weight loss. Am JClin Nutr 66:239-246. Lee CD, Jackson AS, Blair SN. 1998. U.S. weight guidelines: Is it also impor- tant to consider cardiorespiratory fitness? Int J Obes Relat Metab Disord 22:S2-S7. Leermakers EA, Anglin K, Wing RR. 1998. Reducing postpartum weight reten- tion through a correspondence intervention. Int J Obes Relat Metab Disord 22:1103-1109. Leermakers EA, Jakicic JM, Viteri J. Wing RR. 1998. Clinic-based vs. home- based interventions for preventing weight gain in men. Obes Res 6:346- 352. Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, Buchner D, Ettinger W. Heath GW, King AC, Kriska A, Leon AS, Marcus BH, Morris J. Paffenbarger RS, Patrick K, Pollock ML, Rippe JM, Sallis J. Wilmore JH. 1998. Physical activity and public health: A recommendation from the Cen-

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APPENDIXA 239 ters for Disease Control and Prevention and the American College of Sports Medicine. JAm Med Assoc 273:402~07. Perri MG, McAdoo WG, McAllister DA, Lauer JB, Jordan RC, Yancey DZ, Nezu AM. 1987. Effects of peer support and therapist contact on long-term weight loss. J Consult Clin Psychol 55:615~17. Pronk NP, Wing RR. 1994. Physical activity and long-term maintenance of weight loss. Obes Res 2:587-599. Sallis JF, Hovell ME, Hofstetter CR, Elder JP, Hackley M, Caspersen CJ, Pow- ell KE. 1990. Distance between homes and exercise facilities related to fre- quency of exercise among San Diego residents. Public Health Rep 105:179-185. Schoeller DA, Shay K, Kushner RF. 1997. How much physical activity is needed to minimize weight gain in previously obese women? Am J Clin Nutr 66:551-556. Wing RR, Venditti E, Jakicic JM, Polley BA, Lang W. 1998. Lifestyle interven- tion in overweight individuals with a family history of diabetes. Diabetes Care 21:350-359.

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