Weight Management The War on Weight n n

Weight Management

The War on Weight n n n 25% of men and 40% of women are trying to lose weight Approximately 45 million Americans diet each year Nationwide, 55 million Americans are actively trying to maintain their weight

The War on Weight n n n Consumers spend about $30 billion per year on weight related items. This includes diet sodas, diet foods, artificially sweetened products, appetite suppressants, diet books, videos and cassettes, medically supervised and commercial programs, and fitness clubs. Spending on weight loss programs is estimated at $1 to 2 billion per year. U. S. food manufacturers are estimated to have spent $7 billion on advertising of highly processed and packaged foods in 1997.

Why Diets Don’t Work n Obesity is a chronic disease – Treatment requires long-term lifestyle changes n Dieters are misdirected – More concerned about weight loss than healthy lifestyle – Unrealistic weight expectations

Why Diets Don’t Work Body defends itself against weight loss n Thyroid hormone concentrations (BMR) drop during weight loss and make it more difficult to lose weight n Activity of lipoprotein lipase increases making it more efficient at taking up fat for storage

Weight Cycling Typically weight loss is not maintained n Weight lost consists of fat and lean tissue n Weight gained after weight loss is primarily adipose tissue n Weight gained is usually more than weight lost n Associated with upper body fat deposition n

Weight Gain in Adulthood Weight gain is common from ages 2544 n BMR decreases with age n Inactive lifestyle n Goal: not to gain more than 10 -16 pounds more than your weight on reaching the age of 21 n

Changes in Body Composition Fluid is usually the first weight lost n Loss in lean body tissue means lowering the BMR n Weight loss represents a combined loss of lean body tissue and fat n

Lifestyle Vs. Weight Loss Prevention of obesity is easier than curing n Balance energy in(take) with energy out(put) n Focus on improving food habits n Focus on increased physical activities n

What It Takes To Lose a Pound Body fat contains 3500 kcal/lb n Fat storage (body fat plus supporting lean tissues) contains 2700 kcal/lb n Must have an energy deficit of 27003500 kcal to lose a pound per week n

Do the Math To lose one pound, you must create a deficit of 2700 -3500 kcal So to lose a pound in 1 week (7 days), try cutting back on your kcal intake and increase physical activity to create a deficit of 400 -500 kcal per day - 500 kcal x 7 days = - 3500 kcal = 1 pound of weight loss day week in 1 week

Sound Weight Loss Program Rate of loss n Flexibility n Intake n Behavior Modification n Overall Health n

Cutting Back 1200 -1500 kcals per day n Control calorie intake by being aware of kcal and fat content of foods n “Fat Free” does not mean “Calories Free” (or “All You Can Eat”) n Read food labels n Estimate kcal using the exchange system n Keep a food diary n

Regular Physical Activity Fat use is enhanced with regular physical activity n Increases energy expenditure n Duration and regularity are important n Make it a part of a daily routine n

Behavior Modification Modify problem (eating) behaviors n Chain-breaking n Stimulus control n Cognitive restructuring n Contingency management n Self-monitoring n

Chain-Breaking the link between two behaviors n These links can lead to excessive intake n Snacking while watching T. V.

Stimulus Control Alternating the environment to minimize the stimuli for eating n Puts you in charge of temptations n

Cognitive Restructuring Changing your frame of mind regarding eating n Replace eating due to stress with “walking” n

Contingency Management Forming a plan of action in response to a situation n Rehearse in advance appropriate responses to pressure of eating at parties n

Self-Monitoring Tracking foods eaten and conditions affecting eating n Helps you understand your eating habits n

Weight Maintenance n Prevent relapse – Occasional lapse is fine, but take charge immediately – Continue to practice newly learned behavior – Requires “motivation, movement, and monitoring” n Have social support – Encouragement from friends/ family/ professionals

Weight Loss Triad Control Energy Intake Perform Regular Physical Activity Control “Problem” Behaviors

Dieting Can Be Hazardous To Your Health n Weight regained consists of a higher percentage of body fat than before n Less healthy than before dieting n Weight loss diet should not be considered unless you are committed and motivated

Diet Drugs: Amphetamine (Phentermine) n n n Prolongs the activity of epinephrine and norepinephrine in the brain Decreases appetite Not recommended for long term use (dependency)

Sibutramine (Meridia) n n n Enhances norepinephrine and serotonin activity Decreases appetite (eat less) Not recommended for people with HTN

Orlistat (Xenical) Inhibits fat digestion n Reduces absorption of fat in the small intestine n Fat is deposited in the feces, causing side effects n Must control fat intake n Malabsorption of fat-soluble vitamins n Supplements needed n

Very Low-Calorie Diets (VLCD) Recommended for people >30% above their healthy weight n 400 -800 kcal per day n Low carbohydrates and high protein n Causes ketosis n Lose ~3 -4 pounds a week n Requires careful physician monitoring n Health risks includes cardiac problems and gallstones n

Bariatric Surgery An increasingly popular option for severely obese people who are unlikely to lose weight through conventional means n Cost: $20 -$35, 000 n Some insurers cover it n

Candidates for Bariatric Surgery n n n BMI of 40 or more—about 100 pounds overweight for men and 80 pounds for women BMI between 35 and 39. 9 and a serious obesity-related health problem such as type 2 diabetes, heart disease, or severe sleep apnea Willingness to make associated lifestyle changes

Bariatric Surgery Restrictive n Malabsorptive n Combination restrictive/malabsorptive n

Restrictive Surgery: Adjustable Gastric Band

Diet After Surgery After restrictive surgeries, patients can only eat ½ cup to 1 cup of food at a time n Foods often must be soft and chewed thoroughly n Patients who eat too fast or the wrong kinds of food may have vomiting n

Restrictive/Malabsorptive: Roux en Y

Diet Books: Big Business n n n The original Dr. Atkins Diet Revolution is one of the ten best selling books of all time Dr. Atkins New Diet Revolution is still #14 on the NYT paperback advice bestseller list (11/04) having been on the list for years The South Beach Diet has been on the NYT hardcover advice bestseller list for 81 weeks, and is currently #4.

Low Carbohydrate Diets (Past) n n n The Scarsdale Medical Diet The Drinking Man’s Diet Dr. Atkins Diet Revolution The Marine Corps Diet The Last Chance Diet The “Mayo Clinic” Diet

Low Carbohydrate Diets (Recent) n n n n Enter the Zone Dr. Bob Arnot’s Revolutionary Weight Control Program Protein Power Sugar Busters Dr. Atkins New Diet Revolution Feed Your Kids Well (Atkins for Kids) The Fat Flush Plan (Gittleman) The South Beach Diet

Atkins Diet Premise Stabilizes insulin production by limiting carb intake. This forces the body from glucosis into lipolysis, thus ketones are burned as the primary energy source. n This results in a metabolic advantage of low carbohydrate: dieters can lose weight while eating more calories n

Atkins Diet “Induction Phase”: 2 weeks, 20 g carb/day n Eliminate fruit, bread, grains, starchy vegetables, dairy products except cheese, cream, butter n 20 g carb: 3 cups salad greens, or 2 cups salad plus 2/3 cups cooked vegetables such as asparagus, summer squash, green beans n

Atkins Diet Supplements are recommended for everyone: a multivitamin, lecithin, Lglutamine, chromium piccolinate n Can purchase supplements from the Atkins Institute n Recommends exercise n

Atkins Phase 2: OWL “Ongoing weight loss phase” or “Owl. ” n Add carbohydrate at a rate of 5 grams a day until weight loss stops n This is the CCLL: critical carbohydrate level for losing n May be 45, or 33, or 19 grams/day n Continue at this level until desired weight is reached n

Atkins Maintenance Determine CCLM: critical carbohydrate level for maintenance (the level at which weight stabilizes) n Most will stabilize at 25 to 90 grams/day n If weight gain occurs, return to induction diet n

Atkins- Sample Menu Phase 1 B: scrambled eggs and ham, butter, decaffeinated coffee or tea n L: Bacon cheeseburger, no bun, small tossed salad, selzer water n D: shrimp cocktail with mustard and mayo, clear consomme, steak, roast, fish or fowl, tossed salad, diet gelatin with whipped cream, sf beverage n

Atkins: Sample menu OWL B: Western omelet, 3 ounces tomato juice, 2 carbo grams of bran crispbread, decaf coffee or tea n L: Chef’s salad with ham, cheese, chicken and egg; zero carbohydrate or oil and vinegar dressing, iced herbal tea n D: Seafood salad, poached salmon, 2/3 cup vegetable from permitted list, half cup of strawberries in cream n

South Beach Diet Premise n n “Addiction” to carbs is a psychological need for comfort food and is likely a real, physiological phenomenon Eating bad carbs leads to cravings for more which is “ultimately responsible for our obesity epidemic” States that Atkins may limit carbs too severely Stresses glycemic index as the biggest determinant of a food’s potential impact on body weight

South Beach Diet: Phase 1 (2 weeks) n n n Carbs limited to low-carb vegetables, salads, 1% milk, fat-free buttermilk, nonfat yogurt. Proteins: unlimited lean meats, poultry, fish, low fat cheese, tofu Nuts included, but limited “Good” fats including olive, canola oils Sugar-free hard candies, diet gelatin, sugar subs NO fatty meats, starchy vegetables like corn, potatoes, carrots, no fruits, no grains, no alcohol

South Beach: Sample Day Phase 1 n n n B: 6 oz tomato juice, 1/4 -1/2 cup liquid egg substitute, decaf coffee or tea, non-fat milk, sugar substitute snack: 1 -2 turkey roll ups L: SB chopped salad with tuna, sf gelatin snack: celery, 1 wedge Laughing Cow Light Cheese D: baked chix breast, roasted eggplant and peppers, salad, lo sugar dressing Dessert: Mocha Ricotta Creme

South Beach Diet: Phase 2 n n n Reintroduces most fruits, whole grains (sparingly) including popcorn, legumes such as pinto beans, starchy vegetables such as peas, carrots and sweet potatoes, flavored nonfat yogurt, semisweet or bittersweet chocolate, wine Still forbidden: white flour and products made from it including breads, cookies, pasta; potatoes, white rice, corn; fruits including bananas, canned fruit, pineapple, raisins, watermelon Dieters stay in this phase until goal weight achieved

South Beach: Sample Day Phase 2 n n n B: 1 cup blueberries; 1 scrambled egg w/ salsa; oatmeal mixed with 1 cup nonfat milk, sprinkled with cinnamon and walnuts; coffee or tea Snack: 4 oz non-fat sugar-free yogurt L: Tuna salad w/ celery, mayo, tomato, onion in whole wheat pita Snack: 1 part-skim mozzarella cheese stick D: Pan roasted steak and onions, South Beach salad, steamed broccoli; chocolate-dipped strawberries

South Beach Diet: Phase 3 Maintenance- no foods are forbidden n Continue to limit high carb, refined or heavily processed foods. n Return to earlier phase if weight gain occurs n

South Beach vs Atkins Phase 1 n n Atkins Proteins: All meats, poultry, fish, shellfish, eggs, cheese are unlimited Fats: vegetable oils, butter, mayonnaise, heavy cream, bacon Vegetables: 3 cups salad or 2 cups salad and 2/3 cup low carb vegetables NO: artificial sweeteners, margarine, fruits, grains, breads, starchy vegetables, dairy, alcohol n n n South Beach Proteins: Lean beef, pork, skinless poultry, low fat cheese, seafood, eggs Fats: Canola and olive oil Vegetables: salad greens, beans, tomatoes, cabbage, summer squash, broccoli, all low carb are unlimited Dairy: Fat free or 1% milk or yogurt NO: fatty meat, high fat cheese; fruits, grains, breads, starchy vegetables, butter, margarine, alcohol

High Carbohydrate Low Fat Diets The Pritikin Weight Loss Breakthrough n Eat More, Weigh Less (Dean Ornish) n American Heart Association diets n NHLBI TLC diet n

High Carb Low Fat Diets Rationale: diet is high in bulk and fiber, low in calorie density producing early satiety and weight loss n Description: 50 -75% carbohydrate calories, relatively less meat, fish, fats and oils, more grains, cereals, breads, fruits, vegetables n

Sample Menu: High Carb Low Fat n n n B: 1 cup blueberries; oatmeal mixed with 1 cup nonfat milk, sprinkled with cinnamon and walnuts; coffee or tea Snack: 4 oz non-fat sugar-free yogurt L: Vegetarian vegetable soup, fresh orange, nonfat yogurt D: Grilled salmon with yogurt-dill sauce, bulgur with raisins, steamed broccoli; strawberries over angelfood cake Snack: air popped popcorn

Research on Macronutrient Mix in Weight Loss Diets

Low Carb vs Low Fat Diet n n Objective: Compare effects of a low-carb, ketogenic diet (Atkins) with those of a low-fat, low chol, reduced calorie diet Design: Randomized, controlled Subjects: 120 overweight, hyperlipidemic volunteers Intervention: Low carb diet (initially <20 g carb/day) plus nutritional supplementation, exercise recommendation, and group meetings or low-fat diet (<30% energy from fat, <300 mg chol, deficit of 500 -1000 kcal/d) plus exercise recommendation and group meetings Yancy, W. S. et. al. Ann Intern Med 2004; 140: 769 -777

Low Carb vs Low Fat Diet n n Measurements: body weight, body composition, fasting serum lipid levels and group meetings Results: 76% of the low-carb group and 57% of the low-fat group completed the study. At 24 weeks weight loss was greater in the low-carb group (12. 9%) than in the low-fat group (6. 7%) Pts in both groups lost more fat mass (-9. 4 kg low carb, -4. 8 kg low-fat) than fat free mass (-3. 3 kg vs -2. 4 kg) Low carb diet subjects had > decreases in serum triglycerides (-74. 2 mg. d. L vs. -27. 9 mg/d. L)

Expected mean body weight over time, by diet group Yancy, W. S. et. al. Ann Intern Med 2004; 140: 769 -777

Low Carb vs. Low Fat n Low carb group had > increases in HDL-C (5. 5 mg/d. L vs. -1. 6 mg/d. L P<0. 001) n Changes in LDL-C were not significant Low carb group had greater participant retention and greater weight loss over 24 weeks Minor adverse effects were more frequent in the low-carb diet group Limitations: Effects of the low-carb diet and of the nutritional supplements could not be separated. Participants were healthy and were followed for only 24 weeks. n n n Yancy, W. S. et. al. Ann Intern Med 2004; 140: 769 -777

Low carb vs. conventional 1 year follow up n n n Objective: Review the 1 -year outcomes of two groups randomized to these diets 132 obese adults, BMI 35 or greater; 83% had diabetes or metabolic syndrome Participants were counseled to either restrict carb intake to < 30 g/day or reduce calories by 500 cals/day with <30% of cals from fat Stern, L. et. al. Ann Intern Med 2004; 140: 778 -785

Low carb vs. conventional 1 year follow up n n By 1 year, mean weight change for persons on the low carb diet was -5. 1 +/- 8. 7 kg compared with 3. 1 +/- 8. 4 kg for persons on a conventional diet. Differences were not significant (P= 0. 20) Triglycerides decreased more on low carb diet, HDL levels decreased less, Hb. A 1 c improved more Changes in other lipids (LDL, total-C) and insulin sensitivity did not differ between groups Limitations: 34% drop out rate, suboptimal dietary adherence; relatively small net weight loss in both groups Stern, L. et. al. Ann Intern Med 2004; 140: 778 -785

Comparison of mean weight loss in kg between participants on the conventional diet and participants on the low-carbohydrate diet at 6 months (n = 118) and at 1 year (n = 126) Stern, L. et. al. Ann Intern Med 2004; 140: 778 -785

Low Carb vs. Conventional Diet Outcomes n n n Between 6 months and 1 year, persons in the low carb group began to regain weight while persons on the conventional diet continued to lose weight By 6 months, there was no significant difference in weight loss between the two groups Intake data suggest that differences in weight loss, where they exist, are the result of differences in calorie intakes, not a metabolic advantage of low carb

Summary: High Pro Low Carbohydrate Diets n Pros: – High pro low carb diets appear to produce greater short term weight loss – In studies, there was a lower dropout rate with high pro low carb diets – High pro low carb diets produced favorable lipid changes

Summary: High Pro Low Carbohydrate Diets n Concerns – long term safety (effects of high pro diet on kidney function, lack of phytochemicals, association of ↑ red meat and ↑ sfa intake with ↑ cancer) – questionable rationale (protein stimulates insulin release) – difficult to follow long term – epidemiological evidence shows vegetarians are slimmer – at risk nutrients: calcium, potassium, vitamin C, vitamin D

High Carb Low Fat Diets n Pros – Fits most major dietary guidelines including U. S. Dietary Guidelines, TLC diet, AHA diet; high in fiber and plant foods associated with health benefits – Epidemiological evidence associates high carb low fat diets with lower rates of heart disease, cancer, obesity – Consistent with pattern reported by successful dieters in the National Weight Control Registry

Summary: High Carb Low Fat Diets n Cons – Produces more gradual weight loss than high protein diets; dieters become discouraged – Very high carb low fat diets associated with unfavorable lipid changes (may need to choose whole grains, replace some carb with MFA) – At risk nutrients: B 12, D, E, Zinc

Weight Loss By Any Method Will: Reduce blood lipid levels including TC, LDL-C, HDL-C, and Tg n Improve glycemic control n Reduce blood pressure n Especially during active weight loss!

Low Carb vs Low Fat Weight loss is caused by a deficit in calories, not a metabolic advantage of one over the other n Persons with the greatest calorie deficit lost the most weight n A high protein diet may offer some advantages, perhaps in simplicity, limiting options, or increased satiety n

Low Carb vs Low Fat Many VLCD programs offer a high protein, low carb, low fat approach n People should be offered options in weight management n The major issue in diet success is how persons plan to keep the weight off n

Diet Quality of Popular Diets CSFII Data: Healthy Eating Index

Energy Intake of Adults on Popular Diets CSFII DATA

BMI of Adults on Popular Diets CSFII DATA

BMI Vegetarians/Non Vegetarians CSFII DATA

Energy Intake Vegetarians/ Non-Vegetarians (CSFII DATA)

NHLBI Recommendations: Diet Therapy for Weight Mgmt Low calorie diets are recommended for weight loss in overweight and obese persons n Reducing fat as a part of LCD is a practical way to reduce calories. n Plan for a deficit of 500 -1000 kcal/day for weight loss of 1 -2 lb/wk n

NHLBI Recommendations: Physical Activity Physical activity modestly contributes to weight loss, may decrease abdominal fat, increases cardiorespiratory fitness n VERY important for wt maintenance n Initially 30 -45 minutes moderate activity, 3 -5 days a week n Long term: 30 minutes + of moderate intensity activity on most/all days n

National Weight Control Registry Self-selected data base of people who have lost at least 30 lb and kept it off at least one year n Published data on 784 persons, 80% female, 97% white, 56% with college degrees, mean age 45 years n Had average maximum BMI of 35; most had attempted wt loss numerous times n

NWCR: Weight Loss Methods

NWCR: Weight Maintenance Methods

Underweight is Also a Problem 15 -25% below healthy weight or BMI of <18. 5 n Associated with increased deaths, menstrual dysfunction, pregnancy complications, slow recovery from illness/surgery n Causes are the same as for obesity but in the opposite route n

Treatment for Underweight Intake of energy-dense foods (energy input) n Encourage meals and snacks n Reduce activity (energy output) n To gain a pound you need a total excess intake of 2700 -3500 kcal n