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Chapter: Nutrition and Diet Therapy: Diet and Weight Control

Dietary Treatment of Overweight and Obesity

Obviously, if a significant cause of overweight is overeating, the solution is to reduce portion size and caloric intake.



Obviously, if a significant cause of overweight is overeating, the solution is to reduce portion size and caloric intake. This is seldom easy. To accomplish it, one must undertake a weight reduction (low-calorie) diet. For the diet to be effective, one must have a genuine desire to lose weight.


The simplest and, therefore, perhaps the best weight reduction diet is a normal diet based on MyPyramid but with the calorie content controlled.


Exchange lists provide another excellent method to healthfully control the calorie value of the diet. These lists were originally developed by the American Diabetes Association and the American Dietetic Association for use with diabetic patients. They are organized to provide specific numbers of calories and nutrients according to six lists.


Counting fat grams is sometimes used to lower calorie intake. Each gram of fat contains 9 calories, so the reduction of only a few grams of fat per day may result in weight loss. However, for optimal absorption of fat-soluble vita-mins, one requires that at least 10% of daily caloric intake come from fats, and 20% to 35% is the recommended amount for adults. Therefore, in diets limiting fats to 30% of total calories, one must consume 3 grams of fat per 90 calories; in those limiting fats to 20% of total calories, one must consume 2 grams of fat per 90 calories; and in those limiting fats to 10% of total calories, one needs 1 gram of fat per 90 calories. See Table 16-3 to calculate individual fat-gram allowances.


A reduction of 3,500 calories will result in a weight loss of 1 pound. Physicians frequently recommend that no more than 1 or 2 pounds of weight be lost in 1 week. To accomplish this, one must reduce one’s weekly calories (or expend more through exercising) by 3,500 to 7,000, or daily intake by 500 to 1,000. Diets should not be reduced below 1,200 calories a day or the dieter will not receive the necessary nutrients. The diet should consist of 10% to 20% protein, 45% to 65% carbohydrate, and 20% to 35% or less of fat. In other words, normal proportions of nutrients but in reduced amounts. The number of meals and snacks each day should be determined by the dieter’s needs and desires, but the total number of calories must not be exceeded.


There is no magic way of losing weight and maintaining the reduced weight, but there is a key to it. That key is changing eating habits. In fact, unless eating habits are truly changed, it is likely that the lost weight will be regained. The cost of slimness is eating less than one might prefer and exercising most days of the week for 90 minutes.


Food Selection


The dieter must learn to “eat smart.” Daily calorie counting is not necessary if one learns the calorie and fat-gram values of favorite foods and considers them before indulging. Some foods are good choices on weight loss diets because of their low-calorie and low-fat-gram values, and some foods should be used in moderation because of their high-calorie and high-fat-gram values (Table 16-4). The low-calorie, low-fat-gram foods should be used during weight loss and thereafter.

Substitutions of foods with very low calorie contents, preferably nutrient dense, should be made for those with high-calorie contents whenever possible. The following are examples:


Fat-free milk for whole milk


Evaporated fat-free milk for evaporated milk


Yogurt or low-fat sour cream for regular sour cream


Lemon juice and herbs for heavy salad dressings


Fat-free salad dressings for regular salad dressings


Fruit for rich appetizers or desserts


Consommé or bouillon instead of cream soups


Water-packed canned foods rather than those packed in oil or syrup


There are many low-calorie, fat-free, low-fat, sugar-free, and dietetic foods on the market. A food that is said to be fat-free or sugar-free is not calorie-free. The food label must be read to determine if the product can fit into a healthy eating plan for weight reduction. Diet soda can act as a diuretic and can make one hungry, and it should be used in moderation. Ice water with lemon or lime slices makes a pleasant calorie-free drink and helps prevent dehydration.


Some foods that can be eaten with relative disregard for caloric content (provided they are served without additional calorie-rich ingredients) are listed in Table 16-5.

Cooking Methods

Broiling, grilling, baking, roasting, poaching, or boiling are the preferred methods because no additional fat is added, unlike frying. Skimming fat from the tops of soups and meat dishes will reduce their fat content, as will trimming fat from meats before cooking. The addition of extra butter or margarine to foods should be avoided and should be replaced with fat-free seasonings such as fruit juice, vinegar, and herbs and spices.




Exercise, particularly aerobic exercise, is an excellent adjunct to any weight loss program. Aerobic exercise uses energy from the body’s fat reserves as it increases the amount of oxygen the body takes in. Examples are dancing, jogging, bicycling, skiing, rowing, and power walking. Such exercise helps tone the muscles, burns calories, increases the BMR so food is burned faster, lowers the set point, and is fun for the participant. Any exercise program must begin slowly and increase over time to avoid physical injuries.


Exercise alone can only rarely replace the actual diet, however. The dieter should be made aware of the number of calories burned by specific exercises so as to avoid overeating after the workout. General daily guidelines for exercise are 30 minutes to prevent chronic diseases, 60 to 90 minutes to prevent weight gain, and over 90 minutes to maintain weight loss. Children should exercise or be active 60 minutes every day.


Behavior Modification for Weight Loss


Behavior modification means change in habits. The fundamental behavior modifications for a weight loss program are the development of a new and healthy eating plan and an exercise program that can be used over the long term. These are both major lifestyle changes, and one may need to participate in a support group or undergo psychological counseling in order to successfully adapt to these changes.


It is important that one learn the difference between hunger and appe-tite. Hunger is the physiological need for food that is felt 4 to 6 hours after eating a full meal. Appetite is a learned psychological reaction to food caused by pleasant memories of eating it. For example, after eating a full meal, one is unlikely to be hungry. Yet when dessert is served, appetite causes one to want to eat it. One must learn to listen to one’s body and recognize the difference between hunger and appetite. Additional behavior modifications are given below.


·  Weigh regularly (for example, once a week), but do not weigh yourself daily.


·  Don’t wait too long between meals.


·  Join a support group and go to meetings during and after the weight loss.


·  Eat slowly.


·  Use a small plate and fill it two-thirds with fruits, vegetables, and whole-grain products and just one-third with meat products.


·  Use low-calorie garnishes.


·  Eat whole, fresh foods that are low-calorie and nutrient-dense. Avoid processed foods.


·  Treat yourself with something other than food.


·  Anticipate problems (e.g., banquets and holidays). “Undereat” slightly before and after.


·  “Save” some calories for snacks and treats.


·  If something goes wrong, don’t punish yourself by eating.


·  If there is no weight loss for 1 week, realize that lean muscle mass is being produced from exercising or there may be retention of water.


·  If a binge does occur, don’t punish yourself by continuing to binge. Stop it! Go for a walk, to a movie, to a museum. Call a friend.


·  Adapt family meals to suit your needs. Don’t make a production of your diet. Avoid the heavy-calorie items. Limit yourself to a spoonful of something too rich for a weight loss diet. Substitute something you like that is low in calories.


·  Take small portions.


·  Eat vegetables and bread without butter or margarine.


·  Include daily exercise. Park further from work and walk.


Patience and encouragement are needed throughout the adoption of a healthful diet and exercise regime. Temptation is everywhere, and the dieter should be forewarned. Just one piece of chocolate cake could set the diet back for half a day (400–500 calories) and lower resistance to future temptation. Breaking the diet one day will make it seem easy to break it a second day and so on. Fresh vegetables and drinks of water may be used to harmlessly prevent or soothe the hunger pains that are bound to appear. The human body needs at least eight glasses of water each day, and water can give one a feeling of being full. A short walk or a few minutes of exercise may help to turn the dieter’s thoughts from food.

Fad Diets

Many of the countless fad diets regularly published in magazines and books are crash diets. This means they are intended to cause a very rapid rate of weight reduction. Often fad diets require the purchase of expensive foods. Others are part of a weight loss plan including exercise with special equipment. Expensive food items and equipment can add to the burden of dieting.


A crash diet usually does result in an initial rapid weight loss. However, the weight loss is caused by a loss of body water and lean muscle mass rather than body fat. Sudden weight loss of this type is followed by a plateau period; that is, a period in which weight does not decrease. Disillusionment is apt to occur during this period and may cause the dieter to go on an eating binge. This can result in regaining the weight that was lost and sometimes more. This weight gain in turn causes the dieter to try another weight loss diet, creating a yo-yo effect.


Some popular reducing diets severely limit the foods allowed, providing a real danger of nutrient deficiencies over time, and their restricted nature makes them boring. Some provide too much cholesterol and fat, contributing to atherosclerosis. Some contain an excess of protein, which puts too great a demand on the kidneys. Rapid weight loss can cause the formation of gall-stones that could result in the need for surgery.


These diets ultimately fail because they defeat the dual purpose of the dieter, which is to lose weight and prevent its returning. Both can be accom-plished only if eating habits are changed, and crash diets do not do this.


Surgical Treatment of Obesity


When obesity becomes morbid (damaging to health) and dieting and exercising are not working, surgery could be indicated. Two of the surgical procedures used are the gastric bypass and stomach banding. Both procedures reduce the size of the stomach.


In gastric bypass, most of the stomach is stapled off, creating a pouch in the upper part. The pouch is attached directly to the jejunum so that the food eaten bypasses most of the stomach (Figure 16-2). In stomach banding, the stomach is also stapled but to a slightly lesser degree than in gastric bypass. The food moves to the duodenum, but the outlet from the upper stomach is somewhat restricted (Figure 16-2). In both procedures the reduced stomach capacity limits the amount of food that can be eaten, and fewer nutrients are absorbed. Consequently, weight is lost.


These procedures are done only on morbidly obese clients who meet certain strict criteria. A psychological evaluation will also be given to deter-mine if the client is ready to change his or her lifestyle and adhere to healthier eating and an exercise routine. If not, the surgery will not be a success. Also, extensive nutrition counseling with a dietitian will take place before and after the surgery.


Some obese people may feel that this surgery would be a quick fix, but it is not. There can be complications such as bleeding; infections; gastritis; gallstones; and iron, vitamin B12, and calcium deficiencies. Another common complication is “dumping syndrome,” which can cause nausea and vomiting, diarrhea, bloating, and dizziness. Dumping occurs when foods quickly pass into the intestines without absorption of any nutrients. This happens after partial stomach removal or small intestine removal, where food (chyme) dumps directly into the large intestine.

Pharmaceutical Treatment of Obesity


The use of any weight loss medication, whether by prescription or over the counter, should be considered very carefully. Miracles are still in short supply.


Amphetamines (pep pills) have been prescribed for the treatmentof obesity because they depress the appetite. However, it has been learned that their effectiveness is reduced within a relatively short time. The dosage must be regularly increased, they cause nervousness and insomnia, and they can become habit forming. Consequently, they are rarely prescribed now. Over-the-counter diet pills are available. They are intended to reduce appetite but are not thought to be effective. In addition to caffeine and artificial sweet-eners, they contain phenylpropanolamine, which can damage blood vessels and should be avoided.


Some people believe that diuretics and laxatives promote weight loss. They do, but only of water. They do not cause a reduction of body fat, which is what the dieter is seeking. An excess of either could be dangerous because of possible upsets in fluid and electrolyte balance. In addition, laxatives can become habit-forming. They should not be used on any frequent or regular basis without the supervision of a physician.


Although there is no magic pill to help those with excess weight reduce, the wish for one remains, and pharmaceutical companies continue thesearch. Two medications that have recently been approved by the Food and Drug Administration (FDA) are sibutramine (Meridia) and orlistat (Xenical). Sibutramine helps to suppress the appetite and is used in conjunction with a reduced-calorie diet. It is indicated for those with a BMI of at least 30. Orlistat works in the digestive system where it blocks about one-third of the fat in food from being digested. It is recommended that a reduced-calorie diet with no more than 30% from fat be followed when taking orlistat.

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