Scott: Welcome everyone. This is Scott Preston. I am the facilitator for tonight's webinar, which is on Obesity: Lifestyle Interventions. So we have a very exciting webinar this evening. But what I'd like to do is go through some of the formalities to start off with starting with the Acknowledgement of Country. I would like to acknowledge the traditional custodians of the land upon which this webinar is being accessed today. I pay my respect to Elder's past, present and emerging and I would like to acknowledge any Aboriginal and Torres Strait Islander people participating in tonight's webinar.
If you have entered your RACGP number when registering and stay for the whole webinar, you will receive two RACGP activity points for this training. All right, so now that we can interact. Let's get started, we'll move down. There are the learning outcomes. They are set realistic goals as a shared decision making process with your patients. The second one there is outline and approach to physical activity and dietary intervention, which is evidence-based, achievable and sustainable for your patient. And the third one is outlined the role of behavioural management in the lifestyle intervention for your patient.
Okay, let's introduce the speakers. We are very fortunate tonight to have Suzanna Greenwood a dietitian and Megan Achilles an exercise physiologist here to present this webinar. Suzanna is an accredited practicing dietitian with over three years of experience working closely with endocrinologist, Dr David Carry at Health Plus Diabetes Clinic. Suzanna has also worked in private practice in partnership with GPs and gyms. She is experienced in providing medical nutrition therapy for a range of complex conditions. Her special interests include weight management, diabetes, fertility and pregnancy. Suzanna is passionate about education, has designed, and now leads nine different nutrition sessions the clients battling chronic conditions. Her goal is to provide clients with knowledge, skills and confidence needed to cook themselves towards a happier and healthier life.
Meg is an accredited exercise physiologist working with Health Plus Diabetes Clinic together with an endocrinologist and a dietician. She prescribes exercise for clients wanting to lose weight manage their diabetes and change their lifestyle for the long term. Meg has a Masters in Clinical Exercise Physiology and a Bachelor in Exercise and Sports Science and a Bachelor in Psychological Science. She has previously worked in gym and outdoor settings and still teaches gym classes each week. She has also spent eight years as a health consultant evaluating government health programs and services make has a keen interest in helping people develop a positive relationship with exercise and their bodies. Let's hand over to Meg and Suzanna, thanks guys.
Suzanna: Thank you Scott. The way tonight is going to work is I am going to present the first half of tonight's webinar and then I will hand over to Meg to present the second half. To begin tonight's content, it would be helpful for us to refresh just briefly the concept of energy balance. It might seem like weight loss 101, but of course for some of you tonight the concepts that we present will be brand-new. Whereas for others, this is something that you know very well so, bear with us as we do just a little bit of the 101 before we get into more detail. Energy balance is the balance between energy in what you eat versus energy out what you burn. It is quite a simple equation, but it is important to recognize that there are multiple factors that affect both sides of the equation. From the energy intake side of the equation, we have got to think about things like macro nutrient profile, portion size, hunger levels and emotional eating. Then with the energy outside of the equation factors such a such as age and gender, body composition, hormone levels, medications and activity levels are all going to affect that side of the equation. But essentially it boils down to this, if we can consume less energy than we burn we can tip the balance in favour of weight loss. This can be achieved in one of two ways. Firstly by reducing energy intake from foods and beverages which will be the focus of the first part of tonight's webinar. Then secondly, by increasing energy expenditure, which Meg will cover in the second part of tonight's webinar.
When we tip the scales in this way, we refer to it as creating a negative of energy balance or an energy deficit those terms are interchangeable. So at this point, I usually get asked if it's a simple as energy in versus energy out, why are there so many diets out there. Now that is a really good question. There are so many diets out there and each one of them promotes themselves as being more effective than any other diet because of something specific that they do or that they achieve, but when we actually break them down and look at how they work. We are going to see similarities they might all have different rules, but they all boil down to the one thing. So looking at those first three diets there Low-carb, Ketogenic and Low-fat these diets manipulate the ratios of macronutrients, the ratios of protein and carbs and fats to achieve weight loss. The next three diets Intermittent Fasting, Weight Watchers and Light ‘n’ Easy manipulate meal timing and or portion sizes to achieve weight loss. Then the last three diets listed there Shake Diets, Detox Diets and Paleo replace foods of uncertain or unknown energy content with lower energy or less processed options. But, if we look past all of these different rules, we can see that they all act to achieve the same thing and that is an energy deficit and that is why all nine types of diet can be effective because they all create that energy deficit.
So we know it is all about creating the energy deficit but why is it that some diets appear more effective than others? The reason is because it's about the level of energy deficit that can be achieved. So to begin with we've got diets that act in what we call the slow losses own. So these are diets that create only a small energy deficit of about 250 calories or 1,000 kilojoules and these will result in weight loss of about a quarter of a kilo per week. These diets are easy to follow because they can be achieved through quite simple dietary modifications such as swapping full sugar soft drink for diet soft drink, swapping a side of hot chips for a side salad.
Next, we've got diets that are within the hunger zone. So these diets create a moderate energy deficit of about 500 calories or 2,000 kilojoules per day and these tend to result in weight losses of about half a kilo per week. These diets are achievable through more targeted dietary modifications and they usually require a reduction in total food intake rather than just swapping certain foods. This reduction in total food intake means that hunger can begin to become an issue. And for many people it's going to be hunger that will be the reason that they can't continue this type of diet. Dietitians are going to be really helpful in this situation because we can help clients understand the role of protein, fibre and fluid for increasing satiety and then we can help clients understand how to implement that in their day to day eating patterns.
The next level of energy restriction is the supervised zone so diets that a deficit of 1,000 calories or 4,000 kilojoules or more will result in rapid weight loss of about 1 kilo per week. This level of energy deficit is usually unachievable without some sort of appetite suppression. Now, you can achieve appetite suppression through ketosis such as by using a very low energy diet like Optifast or by following a ketogenic diet, or you can use appetitesuppressing medications such as Phentermine. The risk of nutritional energy inadequacy is high with this level of energy restriction. So it's really important that clients are supervised both by a dietitian. But also if they have diabetes, it's important that you their GP or an endocrinologist is monitoring their blood sugar levels and their medications.
So we've established that any diet that creates an energy deficit can be effective for weight loss and that the level of energy deficit will dictate the rate of weight loss, but that still leaves us with the question which is the diet or perhaps better phrased is there even a best diet. To answer that question, let's take a look at what the evidence says. Our first port of call is the NHMRC clinical practice guidelines for the management of overweight and obesity. These guidelines are fairly general, but they do recommend reducing energy intake by about 2,500 kilojoules per day and to tailor programs to the dietary preferences of the individual. And when we look into the NHMRC practice points, the advice again is pretty general firstly that the Australian Dietary Guidelines should be the basis of nutrition advice and secondly that very low energy diets are useful for weight loss and people have higher BMIs when conducted under medical supervision. So the NHMRC guidelines do point us in the right direction, but they don't really answer the question which is the best diet.
So that was a question that the Dieticians Association of Australia sought to answer and to do so they researched and wrote The DAA Best Practice Guidelines for the Treatment of Overweight and Obesity in Adults. Like the NHMRC guidelines, this is a huge document. So rather than taking you through all of it, we're just going to focus on those recommendations which had level A evidence meaning that the body of evidence available can be trusted to guide our practice.
Now the first recommendation with Level A evidence is regarding macronutrient ratios for weight loss specifically comparing high-fat low-carb diets with low-fat high-carb diets. The evidence base for this recommendation included one systematic review and seven RCTs, the systematic review found no difference in weight loss between the low fat and the high fat diets at either 6 or 12 months. And across the seven RCTs, there were also no differences observed. The recommendation that came from this review was that a high-fat low-carb diet is equally as effective in achieving weight loss as a low-fat high-carb diet when protein intake and the level of energy intake a held constant. So in this case, it didn't matter how you modify the ratios of fat or carbs. What mattered most was consuming enough protein and achieving an energy deficit? Is that starting to sound a little bit familiar?
The second recommendation with Level A evidence was regarding very low carb diets without energy restriction versus energy restricted diets in general. Again, the evidence-based was quite good with one systematic review and five RCTs. The systematic review showed no difference between the very low carb diet and the energy-restricted diet in the long-term. So over one to five years and two additional RCTs also showed no long-term difference in weight loss. The recommendation that came from that is that a very low carb diet, so about 20 to 40 grams of carbs per day with no energy restriction is not more effective than an energy restricted diet in achieving weight loss for durations of one to five years.
So at this point, I think a few of you are probably wondering. Okay, well maybe a ketogenic diet, which is a very low carb diet, might be a good option for my clients because instead of restricting energy, they can just restrict their carbs. So let me just clarify something about a ketogenic diet. So a ketogenic diet typically restricts your carb intake to about 5% of your total energy intake which is equivalent in most people to 20 to 50 grams of carbs per day by restricting your carb intake in this manner. It forces your body to switch from burning carbohydrates as the preferred energy source to burning fats, and we know that burning fats for energy produces ketones. That ketones are a natural way to suppress appetite and by suppressing appetite your client then ends up eating less food and less calories and therefore achieving an energy deficit. So it really still comes down to an energy deficit one is just achieving that through less carbs and one is that it just achieving that through other means.
The third recommendation with Level A evidence is regarding formulated meal replacements versus general dietary advice. So with your formulated meal replacements, you're probably familiar with brands such as Optifast or Optislim, but also there are some newer brands on the market such as the Man and Lady shakes. Now for this recommendation, there were seven RCTs reviewed and all seven-showed significantly greater weight loss in the meal replacement group than in the general advice group. You can see here that the meal replacement group achieved weight loss of 2.8 to 18.5 kilos, whereas the general dietary advice group achieved a maximum of 3 kilograms of weight loss and some participants in this group even gained weight. The recommendation that came from this was that a reduction in total energy intake using formulated meal replacements achieves greater weight loss that one to twelve months compared to general advice when monitored by health professionals. Now that monitoring is really important, particularly in two respects firstly to ensure that meal replacements are administered safely and that nutritional adequacy is maintained and the program modified as required and secondly to ensure that clients transition effectively from the meal replacement program to a general healthy diet.
So in summary then which is the best diet. Well what all of the evidence points to is this? That in the end what matters is the degree of energy restriction, and whether or not participants actually comply with and adhere to the prescribed regime, or in simpler language, the best diet is the one that your patient can stick to safely. And if there's one thing that I would hope that you'll take away from tonight's webinar. At least from the diet side of things would be this one statement here. The best diet is the one that your patient can stick to safely. So then, the question is if a patient can stick to a few different diets, is there any particular diet that is going to be most suitable. Now, there's a couple of things for us to consider there, we need to consider the degree of energy restriction, and adherence and unfortunately, we know that these two factors often work in opposition to each other. The greater the degree of energy restriction the harder it is to adhere to and vice versa.
But what I've seen in my own practice is a little bit more complicated than that. For those clients who choose a more restrictive pathway, they can achieve rapid weight loss and this rapid weight loss involves quite visible results and that is really, really motivating for clients when they are putting in the hard yards. However, if your diet is very restrictive, it can be very hard to stick to and in the long-term, you have an increased risk of failure. So it's tempting then to think that a less restrictive pathway is ideal. Yes less restrictive means easier to stick to but less restrictive also means slower weight loss with less visible results. And if you are putting in the hard yards, it's really demotivating not to be seeing the results and therefore a lot of clients will quit the diet after a short period of time because it's just not worth the effort. So it really comes down to the individual client and in that decision making process educating them about what is realistic for them to expect from weight loss. The pros and cons of each different style of diet and the difficulties that they can expect and should be planned for along the way.
Now, you will notice on this slide that I have put the word ‘failure’ in inverted commas and I think that is really important to highlight. The reason I've put that in inverted commas is because I don't believe that people fail at dieting. I believe that diets fail people. So if someone is not having success with a diet, it's not because they are a failure but because the diet was not quite the right fit for them. So, how can we work out? What might be the right fit for your clients? Well, when I do this with my clients in practice, I like to get them to imagine that they have a spectrum at one end of the spectrum we've got those strategies that are really quick and easy to learn and implement. They require minimal planning and preparation and they're very effective in the short term in achieving a larger energy deficit but it's important for clients to understand that strategies at this end of the spectrum are going to be fairly repetitive and therefore boring over a longer period of time. They can be more expensive and they don't usually promote the development of skills or habits there. Therefore best used in the short term to kick-start weight loss increased motivation and increase selfefficacy. At the other end, you've got those strategies that take a little bit longer to learn and implement. They require a bit more planning and preparation and might take a few appointments with the dietitian to build the necessary knowledge and skills. But those skills that are developed and the habits that are formed your patients going to carry forward for the long-term weight maintenance.
So once I have got them imagining the spectrum, I then lay out the different dietary approaches and explain the pros and cons of each. So the first option at the KicStart end of the spectrum is a VLED or a very low energy diet. As we know from the NHMRC guidelines the LEDs are a useful intensive medical therapy for patients with a BMI of 30 or above or 27 and above with comorbidities. A VLED induces rapid weight loss of about 1 to 2.5 kilograms per week with an overall weight loss of about 18 to 20 percent of initial body weight. Which we know is clinically significant a VLED can also improve glycaemic management reduce blood pressure and reduce total cholesterol. And by its very nature being a high-protein lowcarb diet a VLED inducers mild ketosis, which as we said before suppresses hunger and promote satiety. However, not everyone is going to like the taste and the texture of the meal replacement shakes and bars and they can get quite boring quite quickly. This approach can also be really difficult to follow in family or social eating situations or if your client has quite a few dietary restrictions or requirements.
The second option along the spectrum is a delivered meal approach such as Befit Food, YouFoodz or Lite ‘n’ Easy. A program like this is great because it allows clients to eat real food rather than shakes but it still portion-controlled calorie controls and usually fits certain nutrition criteria. A program like this is also going to model appropriate portion size and potentially improve diet quality such as by reducing the amount of refined grains and introducing whole grains, reducing refined sugar, increasing lean protein and introducing a greater quantity and variety of vegetables. However, delivered meals can be quite expensive. They are usually around about ten to twelve dollars per meal and that can add up very quickly if a client is using that for a two meals a day or if the family is going to be using that.
Option number three in the middle here is calorie counting and that can be using an app like Easy Diet Diary or a website or book like Calorie King. This approach can be used on its own or in conjunction with any of the other approaches. In my own experience, I found caloriecounting to be the most effective way of increasing a patient's understanding of energy density and helping them see and become more aware of where some hidden calories might be in their diet. Such as the alcohol that they consume on the weekend, the multiple milky coffees that they have throughout the day, the butter that they spread quite thickly on their morning toast or a might just be snacks that they consume without even realizing it. Calorie counting provides accountability and it also encourages self-monitoring, which we know is a consistent predictor of both short and long-term weight loss. However, this approach requires a significant time investment to learn to track consistently and to track accurately and not everyone has the time or the motivation to commit to doing that.
Option number four on the spectrum is a portion-based approach. This approach is based on the Australian dietary guidelines and looks at food groups and portion sizes. This approach is going to promote diet variety and also promote nutritional adequacy. It can be easily modified to suit different dietary requirements and cuisines and is also easily modified to follow the principles of carb counting for diabetes management. However to educate clients properly in this approach, it takes a good 30-40 minutes and then clients need to practice these skills at home by weighing and measuring foods at least to begin with until they get a really good understanding of the right portions for them.
Then option five at the other end of the spectrum is a personalized meal plan. Now, this one does come with a warning, please wherever possible steer clear of generic meal plans, generic meal plans by their very nature are generic. They don't take into account individual preferences, individual differences in lifestyle or eating habits and they tend to require really significant changes to food choices, which greatly reduces adherence. However, if you work with a dietitian, that dietitian can personalize a meal plan to make sure that it fits with the types of foods and the timing of meals that your client prefers. And by working and developing on that meal plan together your patient can learn skills in portion sizing and recipe modification. A personalised meal plan can also be to find suit the different dietary requirements and cuisines and can provide specific guidance for dietary management of diabetes, high blood pressure or high cholesterol.
So you can see that there are many different dietary strategies that could be used to achieve a negative energy balance for weight loss. What is important, always to remember is that each patient will be different and what will suit one will not necessarily suit another. You really can't take a one size fits all when it comes to dieting and that's where getting an experienced dietitian on board can be very helpful. They can tailor a program to fit to your client's individual needs. What to expect from an appointment with a dietitian. Well where I work and we do a lot of weight loss and a lot of diabetes management. Our first step is always assessment and this is where we look at all of the different factors, which can affect whether a diet or which diet is going to be the best fit for your client. So when I see a client for the first time I spend a good chunk of that appointment asking questions. So I start off by asking questions about their medical history. So how overweight or obese are they, do they have any comorbidities and do they have a history of eating disorders? We ask about social history, so what is their work life like, what about home, what about family members? Do they have a social support around them and what sort of financial capacity have they got available?
We look at their diet in history, so what diets have they tried in the past and what have they learned from those diets? What are the things that help them to lose weight and stick with a diet and what are the things that make that really challenging? We also look at their food, so what are their dietary requirements if they have any. Do they have any specific food preferences, what sort of access to they have to food. Do they have room to store the food and then do they even have kitchen facilities available to cook and prepare that food. We look at their goals as well, so how much weight are they wanting to lose? And when do they expect to lose that by, is weight loss fitting in with some of their other health goals and how does all of this fit in general into their life goals? And then of course motivations, so how motivated is this client and what are their reasons, are their motivations internal or are they external? And once you've done that assessment you can then go through that process of matching the diet to the client. So that's involving a discussion about realistic weight loss, the different strategies and the pros and cons of each. Sort of like we just did before but of course in a
more extended version for our clients.
Once your client has chosen a diet you can then look at goal setting so probably most of you have heard about SMART goals, but it's not something we always have time to follow through with in our consults, but it's certainly something that I work towards with my clients. So SMART stands for Specific, Measurable, Attainable, Realistic and Time-bound and let's talk through each of those individually. So a SMART goal will be Specific it will describe exactly what it is that your client wants to do. It should be Measurable because if you're client can measure their progress they can hold themselves accountable and know if they are succeeding. It should be Attainable, so you need to make sure that your client has the tools the time and the resources they need to achieve that goal. It should be Realistic because if your goal is realistic, you're more likely to have long-term success with that and so starting with small and achievable goals is a really good place to start. And last of all Time-bound, so making sure that your clients goals have a start date, that they detail frequency and that they also have a deadline.
So here on the screen is an example of a SMART goal ‘Beginning on Sunday I will replace one main meal each day with a 350 calorie pre-portioned delivered meal until my review appointment in 2 weeks’ time’. You can see that it is specific; it's very clear as to what it is that your client is trying to achieve its measurable because they can tell if they've replaced one main meal a day. For this client it was attainable, because they have the financial capacity to purchase those pre-portioned delivered meals. Realistic because it really was quite a small change in the big scheme of things and then time-bound it had a start date which was Sunday. It had a frequency, which is once a day and then there was the deadline of when they come back for their review appointment in 2 weeks’ time. So once you've done your goal setting the next thing to do is to review now the NHMRC guidelines recommend reviewing at around two weeks to determine whether the client initial choice of dietary approach was suitable and to modify or change it as necessary. In my own experience, I found it's unlikely that this process will need to be completed. Just the once as your client progresses through their diet as they have ups and downs and face different barriers. The dietary approach will need to be continually modified to keep it working for that client.
Let me give you an example, your client might start off with a calorie counting approach and they decide on doing that particular approach, because they want to learn about the energy content of the foods and beverages they're consuming. Now this approach might work really well for them for a few weeks, but then something comes up at work or at home it occupies a lot of their time and energy. They just don't have time to count calories and in fact, they don't even have time to cook food. So instead of relying on high calorie take away. You could suggest that they move to a delivered meal approach now, they might do this and follow this for a few weeks or months until things calm down at work and they feel ready to get back into more home cooking. But at this point they might feel that they're ready to learn some of those longer-term skills. And so you could look at transitioning them from a delivered meal approach to a portion approach or a personalized meal plan and by reviewing with your clients on a regular basis. It enables you to check in with how they are going to check what is
working and what is not working make modifications and provide the support and accountability and encouragement that they need to continue working towards those goals.
Now once you've gone through this process of reviewing, modifying and reviewing ultimately we all hope that our clients will achieve their goal weight and move on to longterm weight maintenance. In my experience, weight maintenance can be even harder than intervention because during the weight loss phase you're really motivated. You've got a goal that you're heading towards but once you've reached your goal weight. It is very common for clients to relax their eating habits and relax their food choices and when that relaxation moves into a relapse. They are going to be a risk of weight regain, so it's important that clients are aware that weight maintenance is not necessarily going to be easy and they need to be aware that they should have some strategies in place to manage this. Educating about relapse is one important topic to be discussed and according to the DAA guidelines. Relapse’s should actually be expected, planned for and viewed not as a failure, but as a normal part of the change process. This unfortunately is a discussion that often doesn't
happen and I found it to be a key contributing factor to people falling off that bandwagon and not getting back on again.
But if we can educate our clients to expect relapses and help them develop skills and tools to deal with those relapses they’re going to be more able to pick themselves back up again and keep on going. Something like self-monitoring can be a really good way to help identify relapses. So regular weigh-ins and setting what we call a regain limit. The NHMRC guidelines actually mention a regain limit and they suggest a regain limit of about 3 kilograms. The idea here is that a client can identify quite quickly if a relapse has occurred and then take some action to prevent it from blowing out of proportion and being too difficult to come back from. So for an example, you have a client 90 kilos, they lose down to 75 kilos. They might set their regain limit at 78 kilos and whenever they get on the scales and they see seventy eight point zero that is a call to action for them to take some predetermined action to make sure that it doesn't get any higher. So that predetermined action might be using meal replacement shakes for two weeks to get the way back down or it might be booking in to see their option or it might be increasing their exercise from two workouts a week to four workouts a week. It's going to be different for each client.
So at this point, I'm sure many of you are wondering how on earth you are going to have time and your consults to do all of this assessment, discussion, goal setting, problem solving. To be honest that sometimes something that I wonder myself and I get 40 minutes in my initial consultations, which is probably a lot more than many of you get. Now the NHMRC guidelines recommend that while GPs can recommend broad dietary changes development of a tailored program to create an energy deficit may be more cost effective if delivered by an accredited practicing dietitian. So although dietitians tend to be more cost effective cost can still be a key barrier for many people preventing them from accessing a dietitian or continuing to receive the regular support that they need. That's where our GP management plans and our team care arrangements come in. These are Medicare initiatives, which can assist with the cost of appointments as well as facilitate communication between the dietitian and the GP. Now, I'm sure you are all very familiar with TCAs.
But just bear with me for a moment as we recap some important points. First of all to be eligible for a TCA the patient must have a chronic or terminal medical condition that requires ongoing treatment from a multidisciplinary team and according to Medicare chronic medical conditions are those that have been or are likely to be present for at least six months. Now Medicare currently does not actually provide a definitive list of what these chronic medical conditions might be and it's up to the discretion of each GP to determine whether or not a condition is chronic. So I can't recommend strongly enough to consider writing TCAs for your overweight or obese clients to help them get the support they need although overweight and obesity is not yet widely considered a chronic condition. We know that there are so many conditions related to overweight and obesity that would benefit from weight loss. For example prediabetes, diabetes, kidney disease, sleep apnoea, musculoskeletal problems, urinary incontinence, reflux, high cholesterol, high blood pressure, polycystic ovarian syndrome, hyperthyroid and infertility. And those listed here on the slide in bold are actually the ones identified in the NHMRC guidelines as benefiting from weight loss, but we know from our own practice that all of these different conditions can be assisted by weight loss. So please next time you see an overweight or obese client talk with them about the benefits of getting a TCA and do your best to refer them onto an experienced dietitian.
So to summarize for tonight, if there were four things that you could remember from tonight. It would be these, number one weight loss requires an energy deficit, and any diet that creates an energy deficit can be effective. Number two the best diet is the one your patient can stick to safely. Number three an experience dietitian is the best place to tailor a program to fit your patients' individual needs and the number four successful weight loss and weight maintenance requires ongoing monitoring and support from a multidisciplinary team. So that is the energy inside of the equation. I'm now going to hand over to Meg to talk to us about exercise.
Megan: Okay, thank you. Yeah, so for us now with exercise, so we're looking now at the energy out or what you burn or use. So when calculating energy output, we're considering the basal metabolic rate or BMR. So this is the energy a person expends in a day at rest to keep the body functioning. So this is your maintain your body temperature, breathing, blood cell production, cardiac processes, waste disposal. We also consider the thermic effect of exercise that is the calories burned during plan physical activity and the thermic effect of food. This is the energy that is used to digest and absorb food. And finally, it's just good to be aware of adaptive thermogenesis. Which refers to a set point that our body tends to defend in I'm conditions like severe calorie restriction this can cause a drop in resting and non-resting energy expenditure which makes it hard to keep losing weight at the same rate and also makes it easy to regain weight. So it's something that's important to be aware of when your clients are losing weight.
Okay, so thinking about ways that we can increase energy expenditure. There are two main ways exercises a way to increase our energy expenditure and to really hit that energy deficit that Suzanna has just been talking about. Non-exercise activity thermogenesis or NEAT. You might also know this is incidental exercise. This is the energy used for everything we do that is not sleeping, eating or planned and structured exercise. This ranges from the energy use walking to work, typing, gardening, fidgeting and trivial physical activities that increase our metabolic rate. It is the cumulative impact of many factors that culminate in an individual in an individual's daily NEAT or incidental exercise. It's important to note that when people are in a phase of energy restriction or deficit they tend to be less active during the day. So we access or I assess patient's NEAT prior to a weight loss program and this is where fitness activity trackers, fit bits are really helpful here. It doesn't have to be a special Fitbit, the iPhone health app is just as effective as activity trackers in monitoring daily activity. As long as the person keeps their phone with them.
I discuss ways to increase neat with patients in order to keep their activity levels up in the weight loss phase. So we talked about parking further away from their work or using stairs instead of escalators and If and I also talk about having an active mindset. So looking for opportunities to move more during the day and to regularly refer to their activity tracker to maintain that same level, If not increase it then when they started. Also just, a thought it was worth mentioning here, you would have heard about the target of 10,000 steps a day. At the time it was put out there, that actually wasn't any research behind it. I thought this was very interesting, it really was just a simple marketing strategy and it really took hold. There has been research since then and they've looked at where those activity levels are that really have health benefits. So the researchers found that it four and a half thousand steps per day participants had lower mortality rates compared to the least active participants, but if they did more than the mortality rates continue to drop and it petered out at about seven and a half thousand steps. So seven and a half thousand is if you got that I tend to use more in my practice rather than that 10,000 but you will see or I see huge variation among patients and their daily activities some might do a thousand steps others might be doing 15,000 -16,000 steps.
So it's important that I learn what's normal for that individual and then we build from there and on top of our daily incidental activity structured exercise, of course is a great way to increase energy consumption and that includes any planned physical activity. But before we go into how much exercise and what type I just thought it's important to know that exercise alone as a weight-loss strategy is not very effective. So unlike diet if patients restrict their food intake they can have good weight loss success. However to not only to lose weight but keep it off the combination of both diet and exercise is most effective here. So here people really have made a lifestyle change and they've moved into a healthier way of living more generally, but again important to know and Suzanna touched on this before that there's always a high chance that people can regain weight and relapse and again, I like to be very clear with my patients about that.
Okay, so how much exercise should we be doing? So I always refer to the Australian minimum physical activity guidelines, which are the same as the World Health organization's physical activity guidelines. These are to undertake a 150 minutes of moderate activity moderate-intensity aerobic exercise, so this could be walking, swimming, cycling, running, tennis across the week. This can be broken down into five thirty minute bouts of exercise or it could be a 10-minute to the train station the morning, 10-minute walk at lunch and 10-minute walk at the end of the day. However, people can add can do their exercise to add up to that hundred and fifty minutes for higher intensity exercise, It doesn't have to be as much only 75 minutes across the week or any combination of these two. Strength exercises also need to be done twice a week and for older adults anyone above 65 years balance training is important or of course if that's identified as I think that's an area of weakness to somebody. Really for anyone, any exercise is better than no exercise and particularly for some of our patients with obesity and who have no history of exercise or not presently active. These guidelines can be very overwhelming to suddenly talk about a hundred and fifty minutes can be quite intense. So I really just want to encourage people to get moving anyway that they like.
Continuing from this is what our general exercise advice would look like and this is based on the minimum activity that we should be doing or what our patients should be doing. So for extra health benefits and for weight loss more is more this these guidelines go for anyone, the healthy population, people with diabetes, obesity, everyone. It can be more prescriptive and we can work. With heart rate zones or the rate of perceived exertion for exercise sessions. And that's something that I can go into in my role as an exercise physiologist, but really especially patients are just starting out. I just want them to get moving and increasing their heart rate, breathing rate, there the sorts of things that we are aiming for.
I often talk with patients about intensity and how to measure it. I would say for moderate intensity, you can hold a conversation but it struggled to sing for high intensity you wouldn’t be able to hold a conversation. So that's a good easy gauge of how hard you're working. And I think that's a really important point, I think people, often do a lot of walking, but that walking would be it can often be a very comfortable rate. And if you're monitoring your heart rate, it might not really change or you'd be very comfortably holding a conversation. So really that would be a low intensity exercise. All right, so I am probably telling you what you already know, but of course, there are so many benefits to exercise and its way beyond increasing energy consumption. There are lots of comorbidities that can come with obesity. So the impacts of exercise can have on reducing type 2 diabetes and cardiovascular disease risk are so important. As well as improvements in sleep quality in mood and in selfesteem or very beneficial and maintaining that quality of life and quality of movement as we get older.
Okay, so exercise type are there some exercises that are better than others. Well that depends. Yes, there are activities that burn more calories running will burn more energy than walking in the same duration, but if you walk for longer you can burn the same amount of calories. But working with an obese population, my biggest goal is finding an activity that they are comfortable doing they enjoy and they will continue to do long-term. So it will always depend on patient. Thinking longer-term people are more likely to stick it out, if they enjoy it enough. Also other things like social support if it fits into their life, so I often talk about breaking it down into more manageable chunks and educating patients around how small bouts of exercise can be beneficial such as 15 minutes in the morning before work and that can help get people started. It really doesn't matter how you do your 150 minutes. It's really about achieving that and then hopefully going beyond that.
So you might get some questions from your patients around exercise type and you may have heard about high intensity interval training this refers to short bouts of very intense exercise. So this is where you can't hold a conversation. It's usually 8 to 15 minutes and there's broken into exercise efforts from anywhere from 20 seconds to 2 minutes of very high intensity effort, with short recoveries in between high intensity interval training or hit to has the same benefits as moderate intensity exercise but is much shorter and efficient, hit is very good for burning visceral fat. So it's a great exercise strategy, if people enjoy doing that. Other things that was like to talk about is pool based exercise that this could be aqua aerobics, swimming, deep water running, pool exercises, and this is terrific for obese population. In the water provides support, so there is no impact or pain on their joints, which can be a big factor the water also provides resistance. So pool based exercises can be both strength and aerobic water pressure on the body can also help move fluid, which makes this a great option for patients with lipedema.
There are also a lot of online programs which can be appealing and cheap compared to a gym membership and these can work for some people interventions that are effective incorporate program structure, theory of behaviour change components and are interactive and dynamic. So there are some that have lots of social media support. They're okay, but they have limitations and especially really for a client who's new to exercise they offer little supervision of technique and little accountability. It's very easy to log on and then that's it. There are many different gyms offering different styles of training that can be closely supervised or more do it yourself programs again different gyms will suit some people and not others. It's important patients find something they're comfortable with as often the gym environment can be very intimidating and it's important that they find something that's convenient accessible and enjoyable. So this is where an exercise physiologist will come in and work with them to identify what is going to be a good option for them.
Beyond aerobic training, resistance training is also really important. So it resistance training or strength training and as I mentioned earlier we're required to do to strength or resistance training sessions each week. So this is usually six to eight exercises at a time focusing on the major muscle groups. So legs chest back shoulders core so full body workout about 8 to 12 repetitions and two to three sets of each exercise. Resistance training can help with weight loss specifically by increasing the basal metabolic rate through changes in body composition. That is the more lean mass or skeletal muscle mass of person has the higher their resting energy needs resistance training improves insulin sensitivity and improves the breakdown of the lipids in fat or adipose tissue. Strength training also improves self-esteem self-efficacy and perceptions of their own health and variation is important here. Again, the guidelines require both a mix of aerobic training and resistance training and it's the combination of both aerobic and resistance training that is more effective than aerobic exercise alone in reducing body fat.
I think most people imagine that this has to be done in a gym environment but there are lots of exercises that can be done at home or in the park without any equipment. One of my favourite things to do is the sit to stand test. So we actually do this in or I do this in my practice as part of our initial and ongoing assessment of our patient’s strength. So the sit to stand requires a person to go from a seated position on a chair to standing and return back to sitting as many times as they can in 30 seconds. This leaves people breathless and really works the legs. For me, It's an easy way to demonstrate just how simple it is to get your heart rate up and challenge your body with only a chair and I always include it in a program for people new to exercise because it's functional. We do it 20 times a day. It can be done at work at home between Ad breaks at the gym or on a park bench.
When I first meet someone so similar to what Suzanna was touching on. Medical history when assessing a new patient for an exercise program, I consider them medical history what other comorbidities do they have their degree of obesity and their body composition. We get a CT slice their abdomen how much is visceral fat, how much is subcutaneous adipose tissue any joint pain or musculoskeletal injuries? What is their exercise history? What is their exercise history, are they currently active? What do they know about exercise, what have their previous experiences with exercise been like have they previously been active? Also, what are their motivations for coming to see me? We know that most of the time people aren’t initially motivated by their health as that often can be intangible. It tends to be more external or extrinsic motivations. So dropping clothing sizes or losing weight, losing fat, however becomes more intrinsic as they continue on. Social history, what is their day-today like what other life stresses or supports? Do they have do they have children caring responsibilities, financial capacity to pay for gym memberships or pool entries or for health professional support. And accessibility are they a member at a gym or is there one in their office building or apartment building or they near bikeway or park or pool? What do they like, what don't they like and then finally what are their goals. What is it that they want to achieve?
So similar to what Suzanna was saying and I won't go through this in too much detail. But of course we want to be working with our patients to set their goals and will and I work with them according to the smart principle. It needs to be something that the patient themselves have set. I always like to refer everything to the minimum activity guidelines, but I have not ever had a patient come to see me asking to achieve the minimum activity guidelines. Activity track is awesome ways for people to have real-time feedback about their activity that day and then regular review. So I like to see clients at least every month or up to three months depending on where they're at and how much they've seen me and these intervals we do strength and fitness testing to objectively monitor their progress and you at these times we use these reviews to continue to change their goals as they achieve them. You know, they might want to be walking 20 minutes on weekdays and then we might be look to increase that and we'll do fitness monitoring to see how their aerobic activity or the aerobic capacity has changed and also how their strength had been changing as well.
All right, so things are to consider specifically when working with patients with obesity and we've touched on this a little bit, but I wanted to elaborate a bit more number one their tolerance for activity. A lot of patients are not presently active and exercise can hurt and there are reasonable levels of pain that come with exercise, but this might be unfamiliar territory and could be scary for people starting out. Also delayed onset muscle soreness can occur after training when muscles have been challenged more than they are used to and this is normal and goes away after a couple of days. But again, this can be very alarming for people who are new to exercise and haven't experienced this before those with a previous exercise history usually have a better tolerance when starting a new exercise intervention as they're familiar with what is normal.
Two; program progression when somewhere someone starts will be different for each person, but everyone needs to progress slowly if they're not presently active than 5 to 10 minutes of walking four times a week might be enough in the beginning. Looking to increase that by about 10% each week. Injuries or joint pain and this is where pool exercises great or lowimpact options, such as cycling, if someone has gout or a broken foot there are arm work meters. So we have lots of strategies to help deal with the pre-existing injuries of patients or making sure that we're also giving them exercises that aren't going to exacerbate what's currently going. Fluid retention or lipedema, I touched on this before but pool based exercises terrific here. So that water pressure helps move the fluid around and again, it's low impact so no pain or limited pain. Body composition, so I'll give different advice based on fat distribution, so it's visceral versus subcutaneous adipose tissue. I mentioned before HIP training that high intensity interval training, resistance training, visceral fat respond very well to that subcutaneous fat on the other hand tend to recommend that people do pool based exercise, especially in the initial phase of an exercise intervention with a patient that isn't currently active.
I'm a lot more focused on establishing and exercise habit then how much what exercise to do. Once that routine is established and they used to putting time away each day or each week to exercise and it's a priority. Then I can start being more prescriptive about type duration frequency etc., and this comes into ongoing review, so it's great for accountability. I like to see patients usually within a month of when I first seen them. Just so they can report to me and tell me what they have been doing or not doing, then that at more regular review down the track is when we can start to change the program based on how their body is responding and to make sure it keeps challenging their body. So this will be at different intervals depending on the client and where they are at.
So one of our biggest challenges of course is adherence and it will always be a major challenge for anyone undertaking major behaviour change or lifestyle change. Exercise can suffer under periods of stress, fluctuations in motivation, which will absolutely fluctuate previous negative experiences with exercise experiencing pain or injuries and the ongoing financial burden. So I like to educate patients about how exercise can help and to be upfront about possible negative experiences. They may be tired, they will get delayed onset muscle soreness or DOM's, it won't always be fun and you might have to sacrifice other things in your week to fit in the exercise. So I like to say to clients to remind themselves of why they're doing it and also how they feel after an exercise session. Exercise will often drop when there are competing demands and times of high stress and that could be okay if it's temporary or think about ways that you can decrease the volume or frequency for a short time even just getting 10 minutes in the morning during those periods of high stress. It might be uni exams or a big work deadlines and having ongoing support, so working either training with others or review with the health professional, counselling, and peer support those sorts of things.
In summary, we know that weight loss is most successful through the combination of both diet and exercise. The total daily accumulation of energy is the strongest predictor of weight loss and this can be achieved through increasing incidental activity or NEAT, planned exercise and diet restriction, resistance training and aerobic exercise in combination is recommended. The frequency, intensity, time and type of exercise prescribed will based on many individual factors in this is where an exercise physiologist can best work with the patient. But these things will always align with the minimum activity guidelines and require ongoing review and monitoring. My focus personally is to create an exercise habit or an active mindset; however, it might look for that person and then build activity from there. Okay, that's me done.
Scott: Awesome. Thank you very much Megan, Suzanna that that was that was excellent. And I commend you on your on your time management as well, we only went five minutes over so we do have some questions now, Christy has printed out the questions for you guys. I'm going to do my best to read some of these questions and I'm just to do that. I'm going to start from the first question that I can see here. So the first question I have is from Daniel and thank you Daniel. Daniel's question is what is nutritional adequacy with meal replacements? Do you have any comments about that?
Suzanna: Yes. Thank you Scott. So that's a really good question Daniel when we talk about nutritional adequacy for meal replacements we're talking about whether or not the shake has been formulated to provide the majority of a patient's nutritional requirements. So the key thing that I look for when it comes to a meal replacement shake is protein. So a good shake should have at least 20 grams of protein per serve because of a patient were to have three of these a day which you can have on a VLED. Three of these a day would provide 60 grams, which is going to be suitable for a female and a small male, you might need to have more than that for a larger male. The second thing that makes us shake nutritionally adequate is whether it has enough vitamins and minerals to fit the recommended dietary intakes now if you're wondering whether a particular shake is nutritionally adequate you can always have a look on the back of the packet on that nutritional information panel. It will say if it is not nutritionally adequate, it will say that it's not designed to be used as a sole source of nutrition and usually those brands of shakes recommend replacing just one or two a day. The exceptions as I mentioned before are Optifast, Optislim, Kicstart, Man shakes, Lady shakes. Those are probably the main ones that we see here in use in Australia.
Scott: Thank you, Suzanna. The next question is from Athia and the question is, what advice do you give to patients who give pain and musculoskeletal issues as an excuse for not doing exercise.
Megan: Well, we would usually think about other ways that they can exercise that either don't exacerbate those issues or reduce pain. So often water-based exercise being in the pool deep water aerobics is one of the best things especially with patients with obesity where joint pain is a real issue. So you've it's supported and low impact or looking at other options such as cycling or being on the cross trainer at the gym. The elliptical machine again is low impact. Then there are other options as well, if they might want to use medication to help reduce, pain manage that as well.
Scott: Thank you. The third question is from Siddall. And the question is how can we help our patients post bariatric surgery failure?
Suzanna: Yes, wonderful. Obviously a lot of clients go down the route of bariatric surgery as a last-ditch attempt at weight loss. Although many clients have good success, a lot of clients will find that they lose weight and then they regain some of that weight. Now it is normal for that to happen to lose quite a bit of weight and then regain maybe three five eight kilos afterwards because your body is finding that point at which energy intake balances at energy expenditure. But, occasionally you do get those clients who have the bariatric surgery they lose weight, but then the weight just keeps creeping back on. So when I see clients like that, the first thing I do is get them to record a 3 or ideally a seven-day food diary, because what I caught a lot of clients don't realise is that although they might be eating small portions. If the food they are eating is energy dense, then they can be eating the same number of calories as someone who eats much larger portions. So clients who are consuming a lot of alcohol or milky coffees or takeaway or chocolate, these sort of foods are going to fill up their little stomach but are going to give way more calories than they need. So by quantifying how
many calories they're consuming and where they're getting it from we can usually identify what is the problem and then we can help them work out how to adjust their food intake to allow continued weight loss.
Scott: Daniel, thank you for your question. He says that he has patients who've tried Optifast who swear that they didn't lose weight. Are they lying?
Suzanna: Yeah, this is a really good question. So when I have clients who tell me that the first question I ask them is how were they using the Optifast program were they using it to replace one meal to meals or three meals a day and were they replacing meals 5 days a week seven days a week or less. I mean some clients tell me they've done the Optifast program, but they just replaced one meal a day a few days a week which isn't going to really make much of a difference. I have other clients who come in and they were using the Optifast in addition to their current meals, which obviously is not going to help with the weight loss at all. So once I establish how they use the program I then establish what else are they or were they eating. So the Optifast program is very clear on what you can and can't have but often clients are still having their milky coffees, they might still be having their snacks or they might be having meal but that meal contains 700 calories when it should only contain 350. So you really need to get more information to assess whether or not they did the Optifast program according to the recommendations or whether they were doing some variation of it. That didn't end up achieving a calorie deficit.
Scott: Thank you. Okay. Next questions from Naomi, Naomi says wonders. How do we monitor a ketogenic diet and is it safe in type 2 diabetes?
Suzanna: Yes. So the latest guidelines for type 2 diabetes and ketogenic diets do say that they are safe. But as I mentioned during the presentation as with a meal replacement program, it should be under the supervision of a dietitian and either a GP or an endocrinologist because what happens when severely reduce your carbon take is your body then doesn't need to process those carbohydrates that are coming through. So if you're on medications that are designed to reduce your blood sugar levels, you've got the risk of having some hypos there. In terms of monitoring a ketogenic diet it's best to put them under the care of a dietician who can educate them as to how to do it safely and can help them problem solver as they go. I see a lot of clients who are doing here, too, ketogenic diets and over the last four years out of the couple of hundred I've seen I've only seen two clients who have been doing it in a way that is safe and nutritionally adequate. So there's a lot of misinformation online about how to do a ketogenic diet and really if a client is interested. They need to be referred to a dietitian.
Scott: Sorry, this this question is from Tarwood, Tarwood wants to know how to get a list of accredited dietician who don't charge gaps?
Suzanna: Yes. That's a really quick great question, unfortunately, there is no list at the moment that provides that information. If you go onto the DAA website, which is daa.asn.au it will allow you to search for dietitians in your area and search for dieticians who specialize in particular conditions, but unfortunately, there is no list of bulk billing dietitians. The main reason is that the TCA rebate is currently only $53.80 and that allows a dietitian about 15 to 20 minutes for a consult and as we talked about in the presentation the amount of assessment and individualization that goes into an effective weight loss program that just can't be achieved in 15 to 20 minutes. So where possible I'd be trying to send your clients to a dietitian who charges just a small gap so that they can provide not just a generic approach but actually something individualized. To do that it's really about getting to know some of the local dietitians in your area. They might be dietitians attached to certain GP practices. They might be in private practices in which case they've got websites generally or they might be a dietitian attached to a specialist just like I work with an endocrinologist.
Scott: Suzanna, we can certainly, as GPs relate to your concerns about inadequate Medicare rebates feeling your pain there. The next question is how about weight gain during pregnancy? Adrian asked this question. So what are your thoughts about the weight gain during pregnancy and let's assume that its weight gain in excess of what's normal?
Suzanna: So the guidelines at the moment talk about making sure our patients are aware of what the healthy weight gain limit is so for someone of a BMI of 25 that's between 11 and 16.5 kilos throughout the pregnancy. That's a great discussion to have when your client first appears, letting them letting you know that they're pregnant. Unfortunately, I don't know that that happens all that often because there's so many other things that you have to get through during that first appointment, but certainly letting them know that if they're if their prepregnancy weight was 75 kilos, then letting them know based on their BMI, what would be appropriate for them to gain. During that first trimester you'd know you don't want to be gaining any weight at all or a maximum of two kilos to allow for extra fluid volume and then looking at gaining about 400 to 500 grams per week between the second and the third trimesters. If clients are gaining more than that, which would then be a really good time to have a discussion about why the client thinks that is. So is it that they are eating for two hopefully that myth has been well and truly busted for most people but you'd be surprised the number of clients who eat for two is it because they're really tired and they don't have time to cook and therefore they're getting a lot of take away. Is it because they're still feeling quite nauseous and all they can face is lots and lots of toast and crackers. I'm so if you can find out a bit more information, then you may be able to give them some advice yourself or if it's a little bit more complicated than that than referring them on to a dietitian is a good idea.
Scott: Thank you. The next question is from Kate, and Kate would like to know a bit more about the basal metabolic rate set point, can you ever reset this and how can this be combated?
Suzanna: Yeah, so the basal metabolic rate is dependent on your body composition. So looking at your height and weight age and gender but also your fat distribution. It's something that can be measured with a metabolic rate machine, if you have access to one in terms of resetting that I'm sure Meg would tell us that if you can increase your muscle mass because muscle mass is more metabolically active than fat mass than you can actually increase your metabolic rate. But I think maybe the question is more about set point, so there is that set point theory that your body is always going to return to a weight that it prefers. Now what we've seen in practice and what the research points towards is that when you gain subcutaneous fat, so the fact that sits underneath the skin our storage fat that grows not through hypertrophy, so not through expansion of fat cells, but actually through hyperplasia. So looking at the addition of new fat cells and what happens is when you gain weight in those subcutaneous areas you increase your storage capacity. So when you then try and lose weight, you empty those fat cells, but those fat cells sit there still with their storage capacity for around about eight years. So it means that a client who typically maintain their weight at say 70 kilos and maybe for whatever reason put on weight and got up to 90 kilos. They will then find it difficult to maintain at 70 kilos again because they're new storage capacity is set at 90 kilos. So for that client, it's about losing the weight, so emptying those fat cells but then keeping them empty for at least two years, but ideally up to eight years. At which each point enough of those fat cells have died and are no longer contributing to the storage capacity at which point you can then expect a set point for a weight of around about 70, or whatever that original was.
Scott: Thank you. Got another question here from Carolyn and her question is how do you manage weight in patients who had the past history of an eating disorder?
Suzanna: To be honest, that's not something that I do a lot of because I don't work in the space of eating disorders. But as a specialist dietitian what I do for a client who has a present or a very strong pass eating disorder is refer them onto a dietician who specializes in eating disorders, but if the client if the use disorders well and truly in the past. What I would do is take an approach which is more about nourishing your body with the right foods and the right nutrition rather than restricting calories. So you'll remember that portion based approach which was number four on the spectrum, so number four is all about getting the right number of food groups for your body so that you've got the right balance. And so, then you can focus on the positive aspects of food rather than punishing yourself for or being overly obsessive about counting calories.
Scott: That's a list of questions that I've got here. You might flick through your printouts just to see if there's anything that you'd like to answer that, I’ve missed while still thinking about that. I might actually pose a question myself and it provided links in with Carolyn's question. And that is sometimes you see patients that have been on multiple diets in the past and they they're on this vicious cycle dieting. My question is how you get around with these patients the issues with scales and in the guilt that you know gaining weight or not losing weight is induced by stepping on the scales and finding a result that you're not happy with.
Suzanna: Certainly, the majority of clients that I see have done the rounds of the diet's I mean the list of diets they've tried in the past can be quite extensive and for many of them. They can be either obsessed with the scales or fearful of the scales and in both situations. We recommend deciding on and focusing on some goals that are not to do with the kilogram number. So for clients that might be looking at waist circumference and aiming for that recommended waist circumference for risk reduction or it might be fitting into a certain size of clothing or it might be having the energy to go and do what it is that they want to do. So maybe they've got grandkids, they want to be able to play with their grandkids or maybe it's something as simple as climbing the stairs to work without getting puffed. And so helping clients develop a number of goals that are not all just around a number on the scales means that they can have success and they can measure their success and progress across a few different areas.
Scott: Do you put any limits on the frequency of weighing in patients?
Suzanna: I don't have a hard and fast rule but I generally recommend weighing no more than once a week, because if a client is weighing every day or weighing multiple times a day. What they see is fluctuations in fluid status rather than in fat mass and so a client can get on the scales one day and the next day they seem to have gained half a kilo or a kilo and I tell them look that's not going to be reflective of your fat mass that's reflective of your fluid status. Whereas keeping it to once a week at the same time every day. Preferably as soon as you wake up go to the toilet take off all your clothes and jump on the scales and that's going to be your most accurate measure of your true weight status.
Scott: Suzanna and Meg were there any other questions that were printed out that I've missed that you would like to take this opportunity to answer?
Suzanna: There is one question from Armin, which says, what is your suggestion for protein supplements, which are highly advertised particularly for fitness athletes? So that question seems to be talking more about supplemental protein in addition to a diet rather than as a meal replacement for weight loss. So when you're looking at protein supplements, they can be a useful way to meet your protein requirements, especially if you are looking at gaining muscle mass the important thing to look for is a pure protein supplement. So looking for a
whey protein isolate or if not that a whey protein concentrate and trying to find something that has as little added carbohydrates in it as possible. Because you're using it for the protein and not for the carbs but clients need to understand that a protein supplement contains protein and protein contains 4 calories per gram and so if you're consuming this it's still going to contribute calories to your diet and may affect your ability to achieve an energy deficit.
Megan: I was just going to say there was another question here, patients often ask if diet is more important than exercise to achieve weight loss and what's the evidence show or what would we say? I mean certainly from my perspective with exercise, well, I think both are very important. I think you can achieve great weight loss as I mentioned, we started alone, that combination of diet and exercise that helps you achieve weight loss and then keeps it off. And I think the inclusion of exercise is so important for so many other factors beyond weight loss or and also that real change in your mindset and general health. But also it’s important to be mindful with exercise that you know and half an hour of running might be 300 or 350 calories. You can eat that very quickly a muffin might be 400 calories or 500 calories. So making sure people aren't wanting to reward themselves with an exercise session by I can eat that extra muffin today, because you can very quickly kind of undo the calorie work that the exercises done. I definitely think it’s the combination that's important. I don't know if you have anything else to add to that Suzanna.
Suzanna: That is a pretty good summary.
Scott: Just a couple more, there is actually one question here about something called cryo lipolysis. What is the role of cryo lipolysis that was from Jasny and I must admit I don't even know what that is.
Megan: So if you can let us know that it be right, so cryo lipolysis as the name suggests is fat freezing. I'm not aware of any evidence pointing towards that being an effective treatment for overweight or obesity despite what advertisements or loggers might say, so that would not be something I'd be recommending to my clients.
Scott: Okay, that's very clear. Now, we'll make this the final one.
Suzanna: A question from Somad about referrals. The question was most of my patients that I have referred to a dietitian state that the dietitian is not helpful, I've tried one for myself and they only talk about healthy diets, but never do a meal plan. Therefore, most patients are declining a referral to a dietitian, even if it is under a TCA. I have to admit that's probably something that I struggle with a lot as a specialist weight loss dietitian. As I said, previously most of the clients I see have tried every diet under the sun and they've tried multiple dieticians. I usually meet a client for the first time with them having a negative past experience and a negative expectation for the time we're going to spend together. So it is unfortunate that often clients do visit dietitians that they don't feel that they get much out of it. And I think that that's a problem on both sides, I think it's a client not expressing what they want to get out of the appointment and then it's a dietitian not asking the questions to find out what it is that the really wants. So all I can encourage you to do is to get to know the dietitians that work in your area get to know how they practice get to know which ones are going to be supportive of calorie deficit for weight loss. And which are going to be non-diet dietitians, which are dieticians who believe in health at every size and promote acceptance of current weight status rather than a weight loss for health benefits. So if you can get to know just a few of your local dietitians, you'll get a feel for which ones are going to fit in with which of your clients and then hopefully you can refer to the right fit for your client.
Scott: I think that is awesome advice Suzanna. Our time is up on behalf of the RACGP Queensland, Megan and Suzanna I'd really like to thank you for giving up your time on a Thursday evening and for sharing all of your knowledge and expertise with us and thank you to you members and other attendees for joining us tonight. You'll be emailed a short evaluation survey. We would really appreciate it if you could fill that out to help us improve the quality of their education activities in the future. So good night everyone. And once again, thanks very much for joining.