Rena R. Wing, Ph.D. Professor of Psychiatry and Human Behavior Brown Medical School Director, Weight Control & Diabetes Research Center The Miriam Hospital Brain and Behavior: Obesity and Weight Control Brain & Behavior April 2005

Weight = Energy In – Energy Out

Accuracy: Energy intake in one year = 955,000 calories Gaining one pound in one year = 3,500 calories Error of 0.4% or 11 calories per day will produce a weight gain of one pound

Am J Physiol Gastrointest Liver Physiol 286: G7-G13, 2004; 10,1152/ajpgi

Body Mass Index (BMI): kg / m 2Body Mass Index (BMI): kg / m 2 weight in kilograms divided by height in meters squared weight in kilograms divided by height in meters squared Obese: BMI > 30Obese: BMI > 30 Body Mass Index (BMI): kg / m 2Body Mass Index (BMI): kg / m 2 weight in kilograms divided by height in meters squared weight in kilograms divided by height in meters squared Obese: BMI > 30Obese: BMI > 30 Obesity Trends Among U.S. Adults between 1985 and 2002

Obesity Trends* Among U.S. Adults BRFSS, 1985 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

Obesity Trends* Among U.S. Adults BRFSS, 1986 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

Obesity Trends* Among U.S. Adults BRFSS, 1987 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

Obesity Trends* Among U.S. Adults BRFSS, 1988 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

Obesity Trends* Among U.S. Adults BRFSS, 1989 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

Obesity Trends* Among U.S. Adults BRFSS, 1990 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

Obesity Trends* Among U.S. Adults BRFSS, 1991 No Data <10% 10%–14% 15%–19% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

Obesity Trends* Among U.S. Adults BRFSS, 1992 No Data <10% 10%–14% 15%–19% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

Obesity Trends* Among U.S. Adults BRFSS, 1993 No Data <10% 10%–14% 15%–19% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

Obesity Trends* Among U.S. Adults BRFSS, 1994 No Data <10% 10%–14% 15%–19% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

Obesity Trends* Among U.S. Adults BRFSS, 1995 No Data <10% 10%–14% 15%–19% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

Obesity Trends* Among U.S. Adults BRFSS, 1996 No Data <10% 10%–14% 15%–19% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

Obesity Trends* Among U.S. Adults BRFSS, 1997 No Data <10% 10%–14% 15%–19% ≥20 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

Obesity Trends* Among U.S. Adults BRFSS, 1998 No Data <10% 10%–14% 15%–19% ≥20 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

Obesity Trends* Among U.S. Adults BRFSS, 1999 No Data <10% 10%–14% 15%–19% ≥20 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

Obesity Trends* Among U.S. Adults BRFSS, 2000 No Data <10% 10%–14% 15%–19% ≥20 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

Obesity Trends* Among U.S. Adults BRFSS, 2001 No Data <10% 10%–14% 15%–19% 20%–24% ≥25% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

Source: Behavioral Risk Factor Surveillance System, CDC No Data <10% 10%–14% 15%–19% 20%–24% ≥25% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman) Obesity Trends* Among U.S. Adults BRFSS, 2002

Overweight & Obesity in Rhode Island (2003) Overweight38.5% Obese18.4% Obese18.4% TOTAL56.9% TOTAL56.9%

Toxic Environment: Sedentary lifestyles TelevisionTelevision ComputersComputers Cell phonesCell phones Remote controlsRemote controls

Physiological Sociocultural Individual/ Behavioral

A Antecedents B Behaviors C Consequences

A Antecedents B Behaviors C Consequences Low fat, Low Calorie Diet, Physical Activity

A Antecedents B Behaviors C Consequences Low fat, Low Calorie Diet, Physical Activity Stimulus Control Changing Thoughts and Feelings Self -Monitoring, Goal-setting Positive Reinforcers Contingency Contracts

Source of Calories Fat ………………9 calories/gramFat ………………9 calories/gram Carbohydrates ….4 calories/gramCarbohydrates ….4 calories/gram Protein ………….4 calories/gramProtein ………….4 calories/gram Alcohol …………7 calories/gramAlcohol …………7 calories/gram

Low Calorie - Low Fat Diet Recommendations Weight < 200 lbs Weight < 200 lbs % % Weight > 200 lbs % Calories Fat % Fat (g)

Mean Percent Change in Weight among Subjects on the Low Carbohydrate Diet and Those on the Conventional Diet Baseline Carried Forward Analysis Month Low-carbohydrate diet Conventional diet ** NEJM 348;

Weight Loss Maintenance Using Meal Replacements Time (months) Ditschuneit et al., AJCN; 1999; 69: Standard then Meal Replacement Meal Replacement

Law of Thermodynamics Resting Metabolic Rate (65%) Thermic Effect of Food (10%) Exercise(25%) Food and liquid intake (100%) Energy Out Energy In

1.Does exercise alone produce weight loss? Yes – but modest (2-4 kg) Does diet and exercise produce greater initial weight loss than diet only? Yes – but modest (2 kg)Does diet and exercise produce greater initial weight loss than diet only? Yes – but modest (2 kg) Does diet and exercise produce better long- term weight loss than diet only? YesDoes diet and exercise produce better long- term weight loss than diet only? Yes

Long Term Weight Loss StudyDiet OnlyDiet + Exercise Pavlou18 mo-3-11 Sikand2 yr Skendner1 yr yr Wadden1 yr yr Wing1 yr Wing1 yr yr

Physical Activity Strategies Short boutsShort bouts Home exerciseHome exercise Aerobic vs resistanceAerobic vs resistance

Change in Body Weight, kg <150 min/wk >150 min/wk >200 min/wk Dose Response of Exercise on Weight Loss Time, mo

A Antecedents B Behaviors C Consequences Low fat, Low Calorie Diet, Physical Activity Stimulus Control Changing Thoughts and Feelings Self -Monitoring, Goal-setting Positive Reinforcers Contingency Contracts

Modest Weight Loss Improves Health Improves glycemic controlImproves glycemic control Improves cardiovascular risk factorsImproves cardiovascular risk factors Improves psychological well-beingImproves psychological well-being Prevents or delays onset of type 2 diabetesPrevents or delays onset of type 2 diabetes

Diabetes Prevention Program Over 3000 overweight adults with impaired glucose toleranceOver 3000 overweight adults with impaired glucose tolerance Randomly assigned to:Randomly assigned to: –Intensive lifestyle intervention –Metformin –Placebo Followed annually for over 3 yearsFollowed annually for over 3 years

Goal-based Behavioral Intervention An intensive program with the following specific goals:An intensive program with the following specific goals: > 7% loss of body weight and maintenance of weight loss > 150 minutes/week of physical activity

Lifestyle Intervention Results Average activity = 225 minutes/weekAverage activity = 225 minutes/week – 74 % met goal at week 24 –58% met goal at end of study Average weight loss = 7% (7 kg or 14 lb) at week 24 and 4% (4 kg or 8.8 lb) at end of studyAverage weight loss = 7% (7 kg or 14 lb) at week 24 and 4% (4 kg or 8.8 lb) at end of study –50% met 7% weight goal at week 24 –38% met 7% weight goal at end of study

Placebo Metformin Lifestyle Mean Weight Change The DPP Research Group, NEJM 346: , 2002

Incidence of Diabetes Risk reduction 31% by metformin 58% by lifestyle

BRFSS (1996) Data BMI Physician Advised to Lose Weight No Comorbidities5.6% Yes Comorbidities13.6% Trying to Lose Weight If not advised 33.4% If advised77.5%

National Weight Control Registry (NWCR) Founded in 1993 by Drs. Rena Wing and James HillFounded in 1993 by Drs. Rena Wing and James Hill Registry of “successful losers”Registry of “successful losers” Minimum of 30 lbs of weight loss for a minimum of one yearMinimum of 30 lbs of weight loss for a minimum of one year > 18 years of age> 18 years of age

National Weight Control Registry Over 4,000 membersOver 4,000 members Weight loss averages 30 kgWeight loss averages 30 kg –28.7 kg in women –35 kg in men Maintained the minimum weight loss (13.6 kg) for 5.5 yearsMaintained the minimum weight loss (13.6 kg) for 5.5 years 16% maintained the minimum weight loss > 10 years16% maintained the minimum weight loss > 10 years

NWCR: Maintenance Strategies No similarity in how weight was lostNo similarity in how weight was lost Great similarity in how weight is being maintainedGreat similarity in how weight is being maintained –Low fat, low calorie diet –High daily levels of physical activity –Frequent self-monitoring

Current Eating Habits Average intake: 1380 kcalsAverage intake: 1380 kcals Average 24% fatAverage 24% fat Average 5 meals per dayAverage 5 meals per day Most eat breakfast dailyMost eat breakfast daily Eat out 3 meals/weekEat out 3 meals/week Very few follow an “Atkins” type of dietVery few follow an “Atkins” type of diet

Physical Activity in the NWCR 91% report physical activity as an important aspect of weight maintenance91% report physical activity as an important aspect of weight maintenance Most NWCR members far exceeded the 150 minutes per week physical activity goal that is recommended by the Surgeon GeneralMost NWCR members far exceeded the 150 minutes per week physical activity goal that is recommended by the Surgeon General Average of 2600 calories per week of physical activity (equivalent to 1 hour per day)Average of 2600 calories per week of physical activity (equivalent to 1 hour per day)

CONCLUSION Modest weight loss improves health Most effective programs include low calorie/low fat diet, physical activity, and behavior modification Health-care providers are in a unique position to assess, advise, and reinforce weight loss efforts