Weight Loss Strategies for Women

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Weight Loss Strategies for Women
Byung-Kon Yoon, Ph.D., and Len Kravitz, Ph.D.

Introduction:
Obesity has risen to epidemic levels in the U.S., with over 67% of the U.S adults being overweight or obese (National Center for Health Statistics, 2006). Obesity is highly associated with type 2 diabetes and coronary heart disease, and also increases the risk for high blood pressure, stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and some types of cancer (Hu et al., 2001; Thompson et al., 2001). In addition, overweight and obesity and their associated health problems have a significant economic impact on the U.S. health care system. In 2000, the total cost of obesity in the United States was estimated to be $117 billion, of which $61 billion was for direct medical costs and $56 billion was for indirect costs, such as lost days of work (Finkelstein et al., 2003). Women, especially women of ethnicity, have a higher prevalence of overweight and obesity as compared to men. This article will review the factors that contribute to overweight and obesity for women and current concepts and ideas on how to combat this significant health problem.

Obesity and the Environment—Perhaps the Strongest Connection!
From an energy expenditure perspective, it is well-established that overweight and obesity are heavily influenced by a low energy expenditure lifestyle (i.e. little physical activity and exercise) that is combined with a high caloric intake diet. Although this equation is simple to express, many factors contribute to its complexity, especially the environment. It is most apparent that the industrialized and computerized society we live in has contributed dramatically to the sedentary behavior that is prevalent in North American. The need for physical activity in the U.S has become minimal, thus most women and men are spending less and less time and energy doing physical activity and exercise. Combine this with a society that has an over abundance of caloric dense food options (that are relatively inexpensive) and the weight gain cycle continues to grow out of control.

What Affect Does Obesity Have on a Woman’s Psychological Well-Being?
Conventionally, the research has always centered on the physical health consequences of obesity. However, it is meaningful to note that emotional problems such as depression, eating disorders, distorted body image, and low self-esteem are commonly observed in overweight and obese women (Dennis, 2004). It is also intriguing to note that many women who are on antidepressants have been shown to be overweight and/or obese. It is most profound to note that several studies show that women demonstrate striking improvements in mood states and psychological well-being when they start to lose weight (Dennis, 2004).

How Much Does Genetics Contribute to Obesity?
There is no doubt that hereditary factors may combine with environmental, social and cultural determinants to contribute meaningfully to obesity in women (Dennis, 2004). In fact, genes can directly cause obesity in disorders such as Bardet-Biedl syndrome (a syndrome characterized mainly by obesity, retinal degeneration, and renal failure), Prader-Willi syndrome (a complex genetic disorder characterized by obesity and decreased muscle tone), hypothyroidism (under-activity of the thyroid gland that may advance obesity), Cushing's syndrome (a cluster of symptoms caused by the effect of excessive cortisol release that leads to abdominal obesity), and polycystic ovary syndrome (a health problem effecting 5%-10% of women that can adversely affect a woman’s menstrual cycle, fertility, hormones, and insulin production). Although this genetic influence is understood and well-documented, the majority of obesity experts agree that the dramatic increase in obesity in U.S. society the last few decades is not attributable to genetics.

What is the Ethnicity Association with Women and Obesity?
Overweight and obesity are observed in all groups of women, and particularly common among Mexican American, African American, American Indian/Alaska Native, and Pacific Islander women. Being overweight has become a critical problem for Pacific Islander women. Native Hawaiians and Samoans are among the most obese women in the world.

Is Modest Weight Loss Very Meaningful for Obese Woman?
For the obese women, even a modest weight loss of 5% to 10% of initial body weight gives positive results of lowering blood pressure and improving glucose and lipid profiles (Fabricatore and Wadden, 2003). Therefore, modest weight loss is commonly considered an important and very attainable goal for reducing the risks which obesity engenders.

What Behavioral Treatment Techniques are Effective in Managing Obesity?
The ultimate goal of overweight and obesity treatment is to change or modify a woman’s lifestyle. Several behavioral techniques and cognitive strategies have been identified to be statistically significant in weight loss success. These techniques, recently summarized by Costain and Croker (2005), may be incorporated in weight loss programs to help clients attain long-term weight control.
1) Proper assessment of the readiness to change of clients: Some female clients may be thinking about weight loss, other clients are searching for means and ways to affect weight loss (such as popular diet fads), and yet other clients may be starting a weight loss program. Understanding the client’s readiness for change can help the fitness professional in properly guiding and educating her on the path of behavior change.
2) Teaching accurate self-monitoring of food consumption: Costain and Croker (2005) note that significant error exists in what clients perceive they are eating and what they are actually eating. People tend to underestimate how much they are eating. Therefore, basic education in portion sizes in food as well as knowledge about high and low calorie food choices is most consequential to weight loss success.
3) Realistic goal setting: One of the most important behavioral steps in helping women achieve successful weight loss is the goal setting process. Short-term (weekly), medium-term (monthly) and long-term (6 months to a year) goals need to be established and regularly evaluated and updated for clients. A very new strategy in weight loss goal setting is the use of ‘flexible’ goal setting measures (Costain and Croker, 2005). Too often, goals are too rigid in structure and when a client does not attain a certain goal she may assess herself as a failure, and thus drop out of the exercise and weight loss program. The ‘flexible’ goal setting strategy recognizes that lapses (and even relapses) are common occurrences in behavior change with many people and that the client needs to learn to forgive herself for the lapse, fix what may have gone wrong, and get back on track with the established goals.
4) Dietary change: The current emphasis on dietary change is the strategy of individualized diet. Costain and Croker (2005) promote the concept that the initial step of dietary change is to individualize the diet towards the woman’s preferred food choices. Once a client is eating a healthy diet, Costain and Croker suggest that realistic ‘portion’ size control can then be introduced.
5) Increase physical activity: Physical activity and exercise goals are discussed in the next main section and summarized in Table 1.
6) Stimulus control: This is learning how to avoid triggers such as the sight of food and wanting to eat, or dealing with food cravings. For some women, certain situations may trigger food desires. Open discussion of these situations is recommended with the development of possible alternatives to avoid or manage them. For instance, if a client goes to many social events where rich foods are offered (and the temptation to over indulge is present), possibly developing a strategy where the client has a snack before going to the event may help to curb food desires at the event.
7) Cognitive restructuring: This behavioral technique involves learning how to replace unhealthy or negative thoughts and “self-talk” about weight loss with positive affirmations. So often the client has tried weight loss schemes and fads in the past, only to result in unsuccessful outcomes. Thus, when the discussion of weight loss comes up there is much apprehension, discomfort and confusion. For these women, one strategy might be to focus on lifestyle change (instead of popular diets currently being promoted) and to discuss how much more meaningful that is over the long run.
8) Establish ongoing support: Ongoing support involves creative communication techniques such as email messages, phone calls, website communication, and postal mail notes that provide maintenance support and encouragement to clients in an effort to sustain the lifestyle changes that have been made. Ongoing support is one of the greatest contributions every personal trainer and fitness professional can provide to female students and clients seeking weight loss lifestyle changes.
Are There Any Nutrition Education Strategies that Help Women with Weight Loss?
Nutrition education should be directed to help female clients understand the macronutrient composition of foods (e.g. carbohydrate, protein, fat), how to select healthy foods, and how to control portion sizes. Brownell (2004) emphasizes that helping clients create their own individualized dietary pattern is most critical in the weight loss program intervention. Other strategies Brownell suggests for weight loss include using smaller plates, eating slowly, creating a pleasant meal-time ambience and focusing on eating for health. In addition, nutrition education strategies Brownell recommends are careful watching and recording the type and quantity of food that is consumed, weighing oneself regularly (usually once per week), maintaining a weight change chart, and recording one’s emotions with their meals (to become aware of how certain foods may be associated with specific emotions).

What About Physical Activity and Exercise?
Increasing physical activity is a most imperative strategy in the treatment of overweight and obesity. Exercise when combined with caloric restriction is the best approach for long-term weight loss. The addition of exercise to a dietary lifestyle (with restricted caloric intake) helps to decrease total body fat, increase cardiovascular fitness, improve insulin sensitivity and glucose utilization, and lower blood lipids and blood pressure (Despres et al., 1991). The American College of Sports Medicine (ACSM, 2006) provides specific recommendations for a desirable weight loss program (see Table 1). Physical activity serves a primary role in weight management, as well as in weight loss maintenance.

For obese women, even low-intensity walking can be a good strategy for weight loss. Typically, the self-selected walking pace of obese women is slower than normal people, but the average cardiovascular intensity (% of VO2max) for obese women is significantly higher (56% for obese versus 36% for non-obese). However, some obese women experience lower extremity pain in walking from gait irregularities (King et al., 1990). Thus, overweight and obese women are recommended to also include non-weight bearing aerobic activities (e.g. recumbent cycling, regular cycling, rowing, aquatic exercise) and not just walking in their exercise programs. It is essential to note that despite the health benefits of regular exercise for obese women, lack of time is the principal barrier for women in participating in a regular exercise program, followed by lack of exercise facilities, insufficient money (to join a health club or hire a personal trainer), and not having a workout partner (as many women prefer to exercise with others) (Johnson et al., 1990).

Who are the BEST Weight “Losers”—What Does the Research Show?
It is commonly known that women who lose weight often gain it back and sometimes gain back more then when they started the weight loss program. However, great insight can be gained from the study of those women and men who are the most successful ‘losers’ of body weight—these are the 629 women and 155 men from the National Weight Control Registry who have lost 60 pounds or more and maintained this weight loss for 5 years or more. Klem et al. (1997) reports the following consistencies among this highly successful group of women and men in weight loss.
1) They are all physically active. On average they accumulate 250 minutes a week of moderate intensity aerobic exercise. Note in Table 1 that the 2006 ACSM Guidelines recommend 200-300 accumulated minutes of exercise per week for successful weight loss and weight maintenance.
2) They all monitor how much food they each, eating a wide variety of foods, but paying close attention to how much fat is in their diet.
3) Most of them maintain some type of weight change chart.
4) Most of them weigh themselves at least once per week.
5) And recent information on this group shows they all eat a healthy breakfast and are very consistent in their exercise patters.

Summary Thoughts
Successful weight loss and maintenance entails a multifaceted approach of behavior management with nutrition and exercise behaviors that a woman can maintain as a lifestyle. Regularly reinforce a client’s successful steps towards these changes and be prepared to lead her back if she has a lapse or relapse to a previous undesirable behavior. With the ever-increasing prevalence of obesity and the associated diseases, it is imperative for fitness professionals and personal trainers to take the leadership role in steering students towards established strategies that lead to weight loss success.

Table 1. 2006 ACSM Guidelines for Weight Loss Programs
1) Establish a long-term reduction in body weight of at least 5% to 10%
2) The primary mode of exercise should be large group aerobic activities
3) Non-weight bearing activities are encouraged (to avoid orthopedic risk) to include in the exercise program
4) Initial emphasis of the exercise training should be on duration and frequency (keeping intensity moderate and progressing gradually)
5) Frequency of training should be 5 to 7 days per week
6) Accumulate 200-300 minutes of aerobic activity per week (which is equivalent to &Mac179; 2,000 kilocalories of exercise per week); this can be in as little as 10-minute or more bouts of exercise
7) Include a reduction in dietary fat intake to < 30% of total energy intake
8) Emphasize fruits, vegetables, whole grains, and lean sources of protein
9) Create a negative energy balance of 500 to 1,000 kilocalories per day (which is equivalent to a 0.5 to 1 kilogram per week loss of weight)
10) Include the use of behavior management techniques (including relapse prevention)

References
American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription 7th Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.
Brownell, K.D. The LEARN Program for Weight Management 10th Edition, Dallas, TX: American Health Publishing Company, 2004.
Costain, L. and Croker, H. Helping individuals to help themselves. Proc Nutr Soc 2005; 64:89-96.
Dennis, K.E. Weight management in women. Nurs Clin N Am 2004;39:231-241.
Despres, J.P., Pouliot, M.C., and Moorjani, S. Loss of abdominal fat and metabolic response to exercise training in obese women. Am J Physiol 1991; 261:E151-167.
Fabricatore, A.N., and Wadden, T.A. Treatment of obesity. Clin Diabetes 2003; 21(2); 67-72.
Finkelstein, E.A., Fiebelkorn, I.C., and Wang, G. National medical spending attributable to overweight and obesity: How much, and who’s paying? Health Affairs 2003: W3;219–226.
Hu, F.B., Manson, J.E., Stampfer, M.J., et al. Diet, lifestyle, and the risk of type 2 diabetes mellitus in women. N Engl J Med 2001: 345(11);790-797.
Johnson, C.A., Corrigan, S.A., Dubbert, P.M., and Gramling, S.E. Perceived barriers to exercise and weight control practices in community women. Women Health 1990: 16;177-191.
King, A.C., Taylor, C.B., Haskell, W.L., and DeBusk, R.F. Identifying strategies for increasing employee physical activity levels: findings from the Stanford/Lockheed exercise survey. Health Ed Q 1990: 17;269-285.
Klem, M.L., Wing, R.R., McGuire, M.T., Seagle, H.M., and Hill, J.O. A descriptive study of individuals successful at long-term maintenance of substantial weight loss. Am J Clin Nutr 1997: 66;239-246.
National Center for Health Statistics. Health, United States, 2006. U.S. Department of Health and Human Services.
Thompson, D., Brown, J.B, Nichols, G.A., Elmer, P.J., and Oster, G. Body mass index and future healthcare costs: a retrospective cohort study. Obes Res 2001: 9(3);210-218.

Biographies of Authors
Byung-Kon Yoon, Ph.D., earned his doctoral degree in spring 2006 in the Exercise Science program at University of New Mexico, Albuquerque. Presently, he is collaborating on several research projects and papers with colleagues and plans to teach Exercise Science at the University level in his home country of Korea.

Len Kravitz, Ph.D., is the Program Coordinator of Exercise Science and Researcher at the University of University of New Mexico where he recently won the "Outstanding Teacher of the Year" award. Len was honored with the 1999 Canadian Fitness Professional “International Presenter of the Year” and the 2006 Canadian Fitness Professional “Specialty Presenter of the Year” awards and chosen as the American Council on Exercise 2006 Fitness Educator of the Year”.

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