1. Nutrition Interventions in the Treatment of Obesity Dana White, MS, RD, LDN October 25, 2013

2. Outline Problem of Obesity Energy Balance Equation Nutrition Interventions Energy Density Meal Frequency Role of Protein Meal Replacement Products Planning Take home messages

3. Problem of Obesity Data from National Health and Examination Survey 2009-2010 (1): 35.7% of adults in the US are obese 16.9% of children and adolescents in US are obese No change in prevalence of obesity from 2007-2008 to 2009-2010 Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of cancer, some of the leading causes of preventable death. Economic concerns- obese individuals health costs are $1,429 higher than those of normal weight. http://www.cdc.gov/obesity/data/adult.html

4. Energy Balance Equation Graphic: Eat Well, Live Well. A Healthy Way of Life Nutrition Manual. LifeTime Fitness, 2011.

5. Segal KR et al. Am J Clin Nutr. 1984;40:995-1000

6. NUTRITION INTERVENTION 1 EAT MORE, WEIGH LESS

7. Trying to Reduce your Calories?

8. Energy Density of Foods The amount of calories in a particular weight of food (kcal/g). Foods with a lower energy density provide fewer calories than those with a higher energy density High energy density = lots of calories in a small amount of food (think nuts, potato chips, cake) Low energy density = small amount of calories in a lot food (popcorn, non-starchy vege and fruits) 0 --------------------------------9 water fat

9. Weight of Food There is considerable evidence that people eat about the same WEIGHT of food each day. Average ~1000g/day at baseline = 2.2 lbs/day If these grams come from high energy dense foods, that’s a lot of calories. If the grams come from low energy dense foods, you’ll eat less kcal = weight loss…? Ledikwe JH, et al. Am J Clin Nutr 2007; 85:1212-21.

10. Energy Density Food Examples 160 calories / 34g = 4.7

11. Energy Density Influenced by the consumption of fruit, vegetables, fiber and fat. 1. 1. Fruits and vegetables = ↑ water content. Water adds weight but not kcal to foods. 2. 2. Fiber- provides volume, takes longer to digest helping you to feel full on fewer kcal 3. 3. Lower Fat choices - 9 kcal/g versus 4 kcal/g for CHO and Pro.

12. Energy Density Food Examples ≡

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15. The DASH Diet (Dietary Approaches to Stop Hypertension) Born from an initiative of the NHLBI to examine dietary factors that affect blood pressure (1) ↓BP by 13.2/6.1 mmHg among AA w/ HTN (2). Other studies have found DASH to ↓ LDL, ↓ TG and ↑ HDL in pts with DM2 (3), similar results were found in pts on HTN meds on a low calorie DASH and exercise plan (4) What is DASH? CHO: 55%, Fiber: 30g, Pro: 18% ↓ Sodium (<3000mg/d, best BP results with 1500mg/d) 1.http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf 2.Sacks FM et al. Clin Card 1999;22(SIII), III-6-III-10. 3.Azadbakht L et al. Diabetes Care 2011;34)(1):55-57. 4.Miller ER et al. Hypertension, 2002;40:612-618.

16. DASH Diet Plenty Fruits Vegetables Low-Fat Dairy Whole Grain Products Lean Meat, Fish, Poultry Nuts Limit (<5/week) Red Meats Sweets Sugar-Containing Beverages Rich in magnesium, potassium, and calcium 8-12/day 3/day 6-8/day 3-6oz/day 3-6/week

17. Weight Loss Outcomes with DASH PREMIER trial, n=658 obese pts. 3 groups for 6 months 1. 1 advice session only comparison group 2. Intervention group (PA, ↓ Na+ and weight loss) 3. Group 2 + DASH diet (i.e. ↑ F/V) Ledikwe JH, et al. Am J Clin Nutr 2007; 85:1212-21. Weight (kg) p<0.001

18. PREMIER Trial Results Food (g) Accompanied by the largest ↑in fruits, vegetables and dairy and largest ↓ in meat, fats and oils and sweets Ledikwe JH, et al. Am J Clin Nutr 2007; 85:1212-21. Greatest reduction in energy intake seen), BUT, total weight of food increased (+>250g). (+250g). p<0.001

19. PREMIER TRIAL RESULTS Ledikwe JH, et al. Am J Clin Nutr 2007; 85:1212-21. Mean kcal intake ↓ by ~500 kcal/d AND mean weight of food ↑ by ~300g/d (2/3 pound) from baseline.

20. Energy Density and Weight Loss N=97 obese women randomly assigned to reduced fat diet or reduced fat plus fruits and vegetables. No goals for kcal – subjects ate ad libitum. After 1 year, F/V group lost 33% more weight (-8.9kg vs 6.4kg) F/V had ↓ ED, consumed 25% more food AND reported less hunger Better adherence long-term…easier for lifestyle ∆ Ello-Martin JA, et al. Am J Clin Nutr 2007;85:1465-77.

21. How do we help patients do this? Encourage more vegetables- any and all Salads as entrees w/ light dressing ½ plate veggies at dinner time Carrots, cucumbers, red/green peppers, celery with snacks and meals Add vegetables to main dishes- pastas, casseroles, soups, stir fry Add more whole fruits Apples, oranges, grapes, pears, melons, pears, berries, etc Have w/ a protein source Avoid juice Vegetables ProteinStarches

22. How do we help patients do this? Lower the fat content of the diet Choose grilled or baked over fried Use non-stick pans or broths to cook (or small amounts of olive oil) Use tomato-based sauces instead of cream based sauces Use low-fat salad dressings or reduce amount Use low-fat proteins like chicken, turkey, fish (less sausage, bacon, hot dogs, beef) Use low-fat dairy products like skim milk, FF yogurt and low-fat cheese

23. Pasta Makeover Fettucini Alfredo Whole grain pasta with marinara sauce 1 cup = 415 kcals ED: 2.08 1 cup = 222 kcal ED: 1.0 Whole grain pasta w/ vegetables in a marinara sauce 1 cup = 140 cals ED: 0.86

24. Which would fill you up more? =

25. NUTRITION INTERVENTION 2 MEAL FREQUENCY

26. Meal Frequency Eating 1-2 times/day seems to contribute to the problem. Long periods of time between meals can lead to excessive hunger. When hunger strikes, its already too late. Consequences of excessive hunger: Settle for what is closest to you (bday cake, fast food, Cheetos) Make quick decisions (results in poor choices) Take large bites, eat too quickly Eat too much (↑ calories) Results in feeling stuffed, tired, sleepy

27. Meal Frequency Meal frequency inversely related to ↓ body weight in many studies (1, 2) but not all (3) Eating more frequently (i.e. 5-6x/d vs. 2-3x/d) ↓ hunger (3, 2) which aids in better control with food and eating at each eating bout ↑ satiety (2) Better control of insulin and glucose levels (4) May ↑ RMR and thermogenesis (2) – w/ protein 1. Drummond et al. J Obes Relat Metab Disord. 1998;22:105-112. 2. Arciero et al. Obesity 2013;21:1357-1366 3. Bachman, JL and Raynor HA. Obsesity 2012;20:985-992. 4. Munsters MJM and Saris WHM. Plos One 2012;7(6):e38632.

28. NUTRITION INTERVENTION 3 PROTEIN POWER

29. How Much Protein? Current US dietary guidelines recommends ~15% of total calories (75g protein for a 2000 kcal/d diet) Many studies suggesting benefits with 30-35%. That’s 112-150g/d (1500-2000kcal/d) Unlike an Atkins-type diet, new attention with ~30% protein, low fat <30% and moderate carbohydrate~40%. Caution for those with renal issues or h/o gout. Halton T, Hu F. Jour Amer. Coll Nutr. 23:5;373-385 Wycherley et al. Am J Clin Nutr. 2012;96(6):1281-98 Evans et al. Nutr & Metab. 2012, 9:55

30. Role of Protein in Weight Loss Reported benefits of increased protein intake: Increased thermogenesis and RMR Positive effects on body composition, specifically lean muscle mass Enhanced glycemic control Lower energy intake associated with increased satiety Halton T, Hu F. Jour Amer. Coll Nutr. 23:5;373-385

31. Higher Protein, Low Fat Diets Recent meta-analysis of 24 randomized controlled trials (n= 1063). Sig differences in HP group: Body weight (↓0.79kg), FM (↓ 0.87kg) and Triglycerides (↓4.14 mg/dL) Mitigated reductions in FFM (0.43 kg) and RMR (142 kcal/d lesser reduction with HP) 3/5 studies found increases in satiety w/ HP diet Many found ↑ TEM Wycherley et al. Am J Clin Nutr. 2012;96(6):1281-98 Arciero, et al. Obesity. 2013;21(7):1357-66

32. Protein Sources Include with each meal and snack Lean meats- chicken, turkey, lean pork, lean beef Fish and seafood Dairy including yogurt (Greek) and light cheese Eggs Beans/Lentils Soy products (Tofu, Miso) Nuts, seeds Protein powders, shakes and bars

33. Helping Patients Incorporate Protein Have a protein with each meal and snack Toast with peanut butter Greek yogurt and fruit Cottage cheese with fresh fruit Salad with chicken/tuna/turkey and light dressing Lean Cuisine with a salad Cheese stick Hard boiled egg/egg white with fresh fruit ½ cup edamame Protein bar/protein shake

34. NUTRITION INTERVENTION 4 MEAL REPLACEMENT PRODUCTS

35. What is a MRP? A MRP is a portion-controlled food item that contains a balance of carbohydrates, protein and fat as well as vitamins and minerals designed to take the place of a traditional meal or snack. Examples: Liquid meals, meal bars, calorie controlled packaged meals

36. MRPs and Weight Loss Several studies have shown benefits w/ structured meal replacement plans, compared to reduced calorie diet treatments. Several studies have shown benefits w/ structured meal replacement plans, compared to reduced calorie diet treatments. One or two daily vitamin- and mineral-fortified meal replacements, supplemented with self-selected meals and snacks, may be a successful weight loss and weight maintenance strategy for those who have difficulty with self-selection of food and portion control. One or two daily vitamin- and mineral-fortified meal replacements, supplemented with self-selected meals and snacks, may be a successful weight loss and weight maintenance strategy for those who have difficulty with self-selection of food and portion control. Ashley JM, et al. Arch Intern Med 2001; 161: 1599-1604. Lowe, et al. Obesity 2013; DOI: 10.1002/oby.20582

37. When could you use a MRP? When time is an issue When you don’t have time to prepare a meal – cut, chop, cook… When you did not have time to plan or prepare completely for the day You value convenience Easy to throw into a purse, bag or briefcase Very easy to store at work or in the car Easy to open and eat/drink They require very little decision making about what to eat (other than deciding what flavor to choose)

38. When could you use a MRP? Trying to build consistency Help with creating a habit of eating (or drinking) at consistent times each day Need something that’s portion-controlled Exact calories are known More likely to eat less calories when packaged in smaller quantities Easy to account for (calories, protein, etc)

39. Nutrition Facts and MRPs Protein bars/shakes- usually found by pharmacy section of the grocery store. <200 calories, <10g sugar, at least 10g protein Watch sat fat content on protein bars Frozen/pre-packaged meals <300 calories Choose ones w/ meat – chicken, lean beef, pork, or fish Less often the Panini, pizza or pasta-based entrees Choose ones that have more vegetables or consume with side veggies or salad.

40. NUTRITION INTERVENTION 5 BE ONE STEP AHEAD

41. Planning Encourage patients to be proactive. Starts with going to the grocery store on on a regular basis (1/week) Healthy eating requires thought and preparation, but it does not have to be difficult We need to encourage patients to take a moment and think about their day. ASK: Where am I going? What am I doing? What do I need to bring with me?

42. TAKE HOME MESSAGES

43. In Summary Calories matter. Incorporate more low energy density foods (especially more vegetables and fruits (5-9 servings/day)) Consider the DASH diet Work on meal frequency to control hunger Include lean proteins with meals and snacks Plan for the day. Use MRPs. Find accountability to build lifestyle changes

44. Other Factors … Self-monitoring – calorie/exercise tracking apps Sleep – at least 6-8 hours/night Exercise Accountability

45. Thank you!