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Small Changes and the Obesity Epidemic
Len Kravitz, Ph.D.

Article Reviewed:
Hill, J.O. (2009). Can a small-changes approach help address the obesity epidemic? A report of the Joint Task Force on the American Society for Nutrition, Institute of Food Technologists, and International Food Information Council, American Journal of Clinical Nutrition, 89, 477-484.

Body weight and obesity are increasing in all segments of the population in most, if not all, countries around the world. Although most persons are aware that a sedentary existence combined with overeating has negative health consequences, many people are not able to make and sustain the changes to combat this way of life. As well, most people who do achieve weight loss goals regain the weight lost in time (Hill, 2009). Is it inevitable that our society will eventually be obese? The small-changes approach was originally designed to make small lifestyle changes to prevent the gradual gain of weight loss. This strategy has now evolved to be a comprehensive approach of small-changes in diet and physical activity to combat obesity. The concept isn't that small-changes will have greater impact than long changes, but that small-changes are much better than larger weight loss approaches, which simply cannot be sustained.

The Five Reasons The Small-Changes Strategy Can Work
A 17-member task force from the American Society for Nutrition, the Institute of Food Technologists, and the International Food Information Council was established to evaluate the efficacy of the small-changes obesity intervention. The five major reasons this approach to combating obesity may succeed are as follows:
1) Small changes are more realistic to achieve and maintain than large changes. From years of research and observation, the committee agrees that large behavioral and lifestyle changes are most difficult to attain. However, small changes such as 2000 more steps of walking a day (which is about 100 extra kilocalories of energy expenditure) and simple food substitutions (such as replacing a 12-ounce regular soda with a diet soda, saving 150 kilocalories) are doable and maintainable.
2) Even small changes can have an important impact on body weight regulation.
Hill (2009) suggests that most of the U.S. population gradually gains weight over time. He continues that a very slight discrepancy in higher energy intake (diet) with lower energy output (exercise and physical activity) has created an 'energy gap.' This 'energy gap' is estimated to be up to 100 kilocalories/day, with a stored efficiency of body fat to be about 50 kilocalories/day. Thus, as a mean average, most people are gaining about 1 to 2.5 pounds of fat per year (Hill, 2009).
3) Small, successful lifestyle changes lead to increased self-efficacy. Self-efficacy is the impression that a person is capable of performing in a certain manner (i.e., make small lifestyle changes) to attain certain goals (i.e., lose weight and prevent weight regain). The task force suggests that positive changes in self-efficacy (from the success in the small-changes approach) may motivate persons to even greater weight loss progress.
4) The small-changes approach may be applied to environmental forces. Over time, business entities, such as restaurants, food industries, fast-food establishments have created environmental cues, through triumphant marketing (i.e., super sizing meal deals) that encourage excess in food intake. It is hoped that the small-changes approach can be successful in modifying these environmental forces to make 'slight' changes to their offerings (i.e., more snack packs and low-calorie healthy options).
5) The small-changes approach can become a unifying platform for the public and private sectors to work together to combat obesity. The thought is that a combined effort of the public sector and businesses in food sales, distribution and preparation may eventually work together in a common effort to promote a united goal to battle the obesity epidemic.

What Organizations Support the Small-Changes Approach?
The small-changes approach has been widely approved by several leading organizations and groups. The U.S. Department of Health and Human Services has launched a small-changes initiative with television and radio commercials and a website (www.smallstep.gov). This message is supported by the U.S. Surgeon General (http://www.surgeongeneral.gov/priorities/prevention/) which encourages “American families to take small, management steps within their current lifestyle-versus drastic changes changes-to ensure long-term health.” American On the Move (http://aom3.americaonthemove.org/), a nonprofit organization's mission is “to improve health and quality of life by promoting healthful eating and active living among individuals, families, communities and society.” American On the Move advocates an increase in 2000 steps/day and reducing energy intake by 100 kilocalories/day. The American Dietetics Association, the American Heart Association and the American Cancer Society now endorse the small-changes approach. Even some branches of the food industry are starting to 'invest' into this small-changes approach with some reduced portion, lower caloric density food size offerings.

Is the Small-Changes Approach Compatible with Current Physical Activity Guidelines?
Hill (2009) summaries current organization guidelines which now suggest that individuals need to attain minimally 30 minutes/day of moderate-intensity physical activity for health, 60 minutes/day of moderate-intensity exercise to prevent weight gain and 60-90 minutes/day to maintain weight loss and prevent weight gain. However, Hill continues that over the last decade only 26% of the population has been able to meet the minimum (30 minutes/day) physical activity guidelines. In addition, Hill notes that an additional 2000 steps per/day, which is sufficient for burning about 100 extra kilocalories/day would be sufficient for most people not to gain excess weight. The 17-member task force suggests that pedometers may be a very viable (and inexpensive) tool to increase physical activity. Bravata et al (2007) reviewed 26 studies in which pedometers were used to increase physical activity. The average increase from this review was 2491 steps per day, which was an increase in physical activity by 26.9%. Hill notes this is equivalent to walking an additional 20-25 minutes a day and contends this an excellent example of how small-changes to physical activity can be successfully achieved.

How Can a Small-Changes Approach Work with Diet?
At this time Hill (2009) points out that the small-changes approach has not been scientifically tested in population samples to determine its worthiness with dietary changes. He does note that Americans are consuming more reduced-fat milk, which could be considered a significant positive dietary change. As well, many Americans are also now seeking foods without trans fatty acids. Hill states that a small-changes approach can be achieved with reductions in fat and/or sugar intake. For example, sugar-sweetened drink consumption has increased from 222 to 458 kilocalories per day over the past 25 years in the United States. One way food manufacturers can contribute to the small-changes strategy is by reducing the energy density (i.e., kilocalories) in some foods by just adding a little more fiber and water.

Can This Small-Changes Approach Work?
The 17-member task force report believes the small-changes approach can be effective at increasing physical activity, decreasing energy intake and reducing excessive weight gain. The task force statement states that given the 'lack of success' with other weight loss approaches to lifestyle change, the small-changes approach surely deserves genuine attention.

How Can The Exercise Professional Further Help Clients?
Personal trainers and fitness professionals are regularly working with clients who are making the commitment to exercise and improve their quality of life. However, because of the demands of work and family, many individuals are restricted how much they can exercise on a daily basis. Here are some additional steps exercise professionals can incorporate with their clients.
1) Initially do a minute-by-minute “metabolic profile” with each interested client to help the client realize how much sitting he/she is doing on a day-to-day basis (see Too Much Sitting is Hazardous to Your Health in the 2009 IFJ Volume 6, Number 9).
2) Create a 'Challenge' goal for clients to add steps or minutes of movement during their non-active (i.e., seated while working, watching TV or reading, etc.) periods of the day.
3) Create a 'Challenge' goal menu modifier where clients indicate where they have made small-changes to their daily diet (i.e., drinking a health drink versus a sweetened soda, substituting a piece of fruit for a cookie, eating a salad instead of a high-calorie appetizer, etc.)
4) 'Challenge' clients to add 200 extra calories of movement a day (i.e., 2000 extra steps/day) and reduce caloric intake by at least 100 calories.
5) Regularly reward (i.e., certificates of achievement, special prizes, training incentives, etc.) the client as 'Challenge' goals are met and maintained.
Although the future of the small-changes approach to combating the obesity epidemic is unforeseen, for exercise professionals this strategy and practical application provides a new 'tool box' of ideas to use with clients seeking weight loss goals.

Bio:
Len Kravitz, Ph.D., is the Program Coordinator of Exercise Science and Researcher at the University of New Mexico where he won the "Outstanding Teacher of the Year" award. Len was recently honored with the 2009 Canadian Fitness Professional “Specialty Presenter of the Year” award and chosen as the American Council on Exercise 2006 "Fitness Educator of the Year”. He also has received the prestigious Canadian Fitness Professional “Lifetime Achievement Award”.

Additional Resource:
Bravata, D.M., Smith-Spangler, C., Sundaram, V., Gienger, A.L., Lin, N., Lewis, R., Stave, C.D., Olkin, I., Sirard, J.R. (2007). Using pedometers to increase physical activity and improve health. Journal of the American Medical Association, Volume 298 (10), pp. 2296-2304.