Which Weigh to Go? Behavioral and Dietary Strategies for Weight Management March 7, 2013 Presenter: Gary Foster, PhD – Professor of Medicine and Public Health Director of the Center for Obesity Research and Education Temple University Moderator: James M. Rippe, MD – Leading cardiologist, Founder and Director, Rippe Lifestyle Institute Approved for 1 CPE (Level 2) by the Commission on Dietetic Registration, credentialing agency for the Academy of Nutrition and Dietetics. Original recording of the March 7, 2013 webinar and PDF download of presentation available at: www.ConAgraFoodsScienceInstitute.com

Behavior and Dietary Strategies for Weight Management NUTRI-BITES® Webinar Series Behavior and Dietary Strategies for Weight Management This webinar covered: Evidence of diet approaches to weight management Relationship between portion control and calorie balance Identified evidence-based portion control strategies as part of a weight management program

Prevalence of Overweight and Obesity Among US Adults -- Overweight (BMI ≥25) -- Obesity (BMI ≥ 30) Flegal, K et al. JAMA, 2002; Hedley, AA et al. JAMA, 2004;Ogden et al JAMA,2006, Flegal et al. JAMA, 2010

Behavioral Factors Dietary intake Physical activity 4

Portion Sizes Nielsen SJ, Popkin BM. JAMA 2003

Behavioral Treatment of Obesity Consists of a set of principles and techniques to modify eating and activity habits Treatment is designed to increase skills not insight Treatment recognizes non-behavioral causes of obesity Foster, Makris, Bailer. AJCN. 2005. 6

Self monitoring in weight loss: a systematic review 15 studies found a significant association between dietary self-monitoring and weight loss Dietary Intake Participants with the most complete food records lost significantly more weight than those who had less complete records 5 studies discussed the use of records for tracking exercise behaviors Physical Activity Consistent self monitors of exercise achieved significantly greater weight loss and experienced fewer difficulties with exercise, and exercised more often Weight self-monitoring increases participants’ awareness of weight and related energy intake & expenditure Weight More frequent weighing is associated with greater weight loss Burke LE et al. JADA 2011. 7

Lifestyle Modification for Weight Control Reduce energy intake by 500-1000 kcal/day (by reducing portion size, fat, and sugar). Exercise > 180 min/week. Record food intake, physical activity, and weight. Set realistic goals for weight loss (5%-10% loss to improve health and well being). Diabetes Prevention Research Group, NEJM, 2002

Portion-Controlled Meals Provides fixed-portion and calorie amounts Counters underestimation of portion and calories Reduces choices and contact with problem foods Are convenient to use Satisfies appetite (monotony and sensory specific satiety) Facilitates dietary adherence

Percentage Weight Loss Meal Replacements Enhance Initial and Long-term Weight Loss 15 10 5 Time (mo) Phase 2 Phase 1* MR-2 2 4 6 8 12 18 24 30 36 45 51 MR-1 Percentage Weight Loss CF The use of liquid formula meal replacements and snack replacement bars can enhance long-term successful weight management. This figure shows the results of a two-phase clinical trial conducted at the University of Ulm Obesity Center in Germany [1,2]. In phase 1 (3 months), 100 subjects were randomized to receive a 1200–1500 kcal/d diet given as three meals and two snacks of conventional food, or an isoenergetic diet (1200–1500 kcal/d), in which two of the three meals and both snacks were replaced with commercially-prepared liquid meals (shakes, soups, hot chocolate) and snack replacement bars. In phase 2 (48 months), all subjects were instructed to replace 1 meal and 1 snack with meal and snack replacements daily. During phase 1, subjects randomized to meal replacement therapy lost more weight (7.8%) than those randomized to a conventional food diet (1.5%). Therefore, meal replacement therapy improved short-term compliance with a low-calorie diet. Seventy-five percent of the participants continued to replace 1 meal and 1 snack every day for 4 years and maintained long-term weight loss [2]. 1. Ditschuneit HH, Flechtner-Mors M, Adler G. Metabolic and weight loss effects of long-term dietary intervention in obese subjects. Am J Clin Nutr 1999;69:198-204. 2. Flechtner-Mors M, Ditschuneit HH, Johnson TD, et al. Metabolic and weight-loss effects of a long-term dietary intervention in obese patients: a four-year follow-up. Obes Res 2000;8:399-402. *1200–1500 kcal/d diet prescription. CF=conventional foods. MR-2=replacements for 2 meals, 2 snacks daily. MR-1=replacements for 1 meal, 1 snack daily. Ditschuneit et al. ,Am J Clin Nutr, 1999 Fletcher-Mors et al., Obes Res, 2000

Meta-Analysis of Partial Meal Replacements (PMR) vs Meta-Analysis of Partial Meal Replacements (PMR) vs. Reduced Calorie Diets (RCD) *p<.001 *p<.001 Weight Loss (in kg) Heymsfeld et al. IJO, 2003

Look AHEAD Study Design 5145 obese participants with type 2 diabetes SAMPLE Usual care (Diabetes Support and Education Group) Usual care + Lifestyle Intervention RANDOMIZATION 12 years, with 4 years of intensive intervention STUDY DURATION Cardiovascular deaths (fatal MI and stroke) Nonfatal MI Nonfatal stroke PRIMARY OUTCOME The Look AHEAD Research Group, Controlled Clinical Trials, 2003

Changes in Weight and Hemoglobin A1c in Obese Individuals with type 2 diabetes 100 Participants (59 women, 41 men) 55.6 ± 10.6 years old 36% White 35.8 ± 5.3 kg/m2 BMI 59% African American 7.7 ± 1.3% A1c Participants were randomly assigned to either a 6 month, 9-session: Lifestyle intervention that included a portion-controlled diet (PCD): Nutrisystem® D™ Diabetes self-management (DSME) Primary outcome was change in weight, secondary outcome was change in HbA1c Foster et al. Nutr Diab, 2013

Results * * * ** * p<0.0001 **p<0.05 Foster et al. Nutr Diab, 2013.

Reducing energy intake Relationship between portion control behavior and other weight control behaviors Self-monitoring Greater ease Reducing energy intake Reduce portion Reduce frequency Consume an alternative Stimulus control Limits environmental cues