1. 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:

2. 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

3. 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

4. Behavioral Factors
Dietary intake
Physical activity 4

5. Portion Sizes
Nielsen SJ, Popkin BM. JAMA 2003

6. 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 6

7. 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

8. Lifestyle Modification for Weight Control
Reduce energy intake by 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

9. 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

10. 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:
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:
*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

11. 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

12. 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

13. 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

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

15. 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