1. Treatments for Overweight and Obese Clients Dr. David L. Gee FCSN/PE 446 Nutrition, Weight Control & Exercise

3. Assessment of Healthy Weight Body Mass Index (>25) Risk factors for chronic disease –High waist circumference –blood pressure (hypertension) –blood lipids (dyslipidemia) TC, LDL-C, HDL-C, TG –Impaired glucose tolerance –family history Presence of obesity related disease

4. The Bottom Line on Weight Control Regardless of the characteristics of a weight loss program: Negative Energy Balance –Results in weight loss –E(in) is less than E(out) Positive Energy Balance –Results in weight gain –E(in) is greater than E(out) Energy Balance –Results in weight maintenance –E(in) is equal to E(out)

5. Treatment Affecting Energy Intake Listed from low to high risk Healthy diet approach (w/BM) Balanced hypocaloric diet (w/BM) –Low Calorie Diet (LCD) Drugs Very Low Calorie Diets Gastric & Intestinal Surgery

6. Treatment Affecting Energy Expenditure & Losses Increase lifestyle activity Aerobic exercise (w/BM) Strength training (w/BM) Drugs (no prescription drugs currently approved)

7. National Weight Control Registry (University of Colorado) ~3000 people kept >30 lbs off > 1year –average BMI 35 => 25 –Average lost 60 lbs, kept it off for 5 years many were overweight as children (2/3), had one or both parents overweight (60%) average age 45 yrs http://www.uchsc.edu/nutrition/WyattJortberg/nwcr.htm

8. Seven Tips from the National Weight Control Registry CNN – “Fat Chance”, Nov 2003 Expect failures but keep trying –Don’t view past failures as signs you can’t succeed Don’t deny yourself –Plan indulgences Weigh yourself regularly

9. Seven Tips from the National Weight Control Registry CNN – “Fat Chance”, Nov 2003 Exercise regularly –Walking most popular Add a little bit of exercise to your daily activity Eat a high CHO/low fat diet Eat 5 meals a day

10. Other Tips from the National Weight Control Registry No pain, no loss Make smaller lifestyle goals Exercise & Diet (90%) Do what you want, not what you should.

11. Major Dietary Approaches For Weight Loss Healthy Diet/Non-Diet Approach –DASH, Food Guide Pyramid Balanced Reduced (Hypocaloric) Diet –Weight Watchers, Jenny Craig, Slim Fast Low Carbohydrate Diet –Dr. Atkins Restrained Carbohydrate Diet –South Beach Diet, Zone Diet

12. Treatments for the Overweight Patient (BMI 25-30) The Non-Diet or Healthy Diet Approach Focus on becoming healthy Success is measured in “units of health”, not units of weight Strategies are lifetime, not temporary Make a commitment because you want to, not because you have too.

13. Dietary Modification for the Overweight Patient Focus first on the quality of the diet, second on the quantity. –Food Guide Pyramid –Dietary Guidelines for Americans –DASH diet www.nhlbi.nih.gov –Focus on fruits, vegetables and whole grains

14. Food Guide Pyramid (the New Food Pyramid has different pyramids based on energy needs) Energy Intake 1600 kcal2200 kcal2800 kcal Grain6911 Vegetable345 Fruit234 Meat (oz)567 Fat (g)537393 Added sugar (tsp) 61218

15. Portion distortion

16. Healthy Diet Effects Healthy diet may or may not result in weight loss –if weight loss occurs, it will be gradual Healthy diet should result in improved health Improved health may require more significant weight loss A healthy diet is probably the best diet for long-term weight maintenance

17. Final Exam – 2005 Required Readings NIH – Clinical Guidelines WIN Publications (Weight Information Network) –Statistics –Weight Cycling –Very Low Calorie Diets –Surgical Treatments for Obesity –Pharmacological Treatments for Obesity Nutrition Club – Tuesday, 5:30PM, 126 Mich –2005-06 officer elections –Salmon BBQ

18. Balanced Hypocaloric Diet “Low Calorie Diet” –LCD, not VLCD For those who are : –significantly overweight BMI >25 w/ health risks –can not attain good health without significant weight loss

19. Balanced Hypocaloric Diet Negative energy balance –Energy In < Energy Out -500 Cal/day energy balance = 1 lb fat/week weight loss -EB achieved with COMBINED –dietary caloric restriction –increased exercise –plan a net -EB of -500-1000 Cal/day

20. Negative EB is Accumulative If EB = - 200 Cal/day –decrease food by 100 Cal/day –increase activity by 100 Cal/day In one month EB = - 6000 Cal at 3500 Cal / lb FAT => almost 2 pounds per month over 20 pound per year weight loss

21. Composition of Balanced Hypocaloric Diets Calories –reduce intake by about 500 Cal/d –minimum of 1000 Cal/d Estimate calories –Calculate energy expenditure –Food records

22. Composition of Balanced Hypocaloric Diets Low Fat – < 25% of calories Moderately high in complex CHO – ~ 60% of calories –Unless pt w/ hypertriglyceridemia Reduce CHO 45-50% of calories Fat 30-35%, mainly unsaturated fats Adequate in proteins – > 0.8 gP/kg BW

23. Forms of Balanced Hypocaloric Diets Meal Plans –Dietary exchanges Weight Watchers –Commercial Diet Packages Jenny Craig NutriSystems –Food Supplement/Food Combos Slim Fast

24. Metabolic and Weight Loss Effects of Long-term Dietary Intervention in Obese Patients: Four-year Results Flechtner-Mors M, et al. Obes Res. 2000;8:399-402. Randomized controlled trial –75 subjects followed for 4 yrs –Control vs Slim-Fast program Wt loss at 4 yrs –Control: 3.2% SF: 8.4% Fasting blood glucose at 4yrs –Control: 13% lower SF:12% (ns) –Similar findings with fasting insulin Systolic and fasting TG lower in SF group

25. Advantages of Balance Hypocaloric Diets Safe High quality weight loss More similar as a “Diet for a lifetime” Large volume of food No elimination of any food or food group

26. Disadvantages of Balanced Hypocaloric Diet Another “diet” –going on, going off Slow rate of weight loss –think long term No “magic”, no gimmick

27. Final Exam – 2004 Exam Format (see 2003 Study Guide linked on course web page) –No questions on Ergogenic Aids ! –Short answer/essay Hypothetical case study –Data on height, weight, risk factors –Do assessment, establish weight goal –Common questions a client might ask –MC/TF Information that you might be asked from clients and health professionals Research studies presented are to reinforce and confirm relationships between obesity, weight loss and disease risk.

28. Dietary Means to a Healthy Weight Low Carbohydrate Diets Characteristics –Very low in CHO Induction phase: < 20g/d Maintenance phase: 40-60g/d –Restricted intakes of fruit, cereals, pasta, bread, potatoes, rice –Caloric intake not specified Examples –Atkins diet

29. The High Protein/Low Carbohydrate Diets : Rationale: The high CHO/insulin link The Claim: –High CHO diets result in hyperinsulinemia –Insulin stimulates fat synthesis –therefore high CHO diets result in gaining fat weight

30. The High Protein/Low Carbohydrate Diets: Flaws in Rationale The Reality: Hyperinsulinemia is a result, not a cause, of obesity Although insulin does stimulate fat synthesis: –fat synthesis only occurs with +Energy Balance –fat synthesis from CHO is inefficient and with +EB, body preferentially stores excess dietary fat as body fat

31. Carbohydrate intake and biomarkers of glycemic control among US adults: NHANES III AJCN 77:1426-1433 (2003) 5730 men, 6125 women –Cross-sectional NHANES III study Divided into quintiles based on % CHO calories No association between CHO intake and: –HB A1c concentration –Fasting plasma glucose –Fasting serum insulin “this supports current recommendations regarding carbohydrate intake in healthy adults.” (also note international epidemiological studies)

32. The High Protein/Low Carbohydrate Diets : Rationale: Epidemiological Evidence The Claim: –Since the 1950’s % FAT has fallen from about 40% to about 34% –Since the 1960’s the % obese has risen from 25% to about 33% Therefore, hi CHO diets have contributed to the increase in weight problems

33. The High Protein/Low Carbohydrate Diets: Flaws in Epidemiological Evidence The Reality: –Studies show that despite an increase in %CHO in diet, there is increasing obesity. –But, while %CHO increased & %FAT decreased –TOTAL Calories increased –caloric expenditure decreased –absolute fat intake stayed the same.

34. The High Protein/Low Carbohydrate Diets: Realities Diets low in carbohydrate will deplete glycogen stores –result in significant early water loss –cause premature fatigue during exercise

35. The High Protein/Low Carbohydrate Diets: Realities High protein diets will result in further weight loss if E in < E out –meat, cheese, egg diets become unappetizing over the long run –long-term compliance to this restricted diet is likely to be poor Diets high in meat … are high in saturated fats and may increase risk of heart disease. –Short term (during active weight loss) may see improvement in blood lipids

36. The High Protein/Low Carbohydrate Diets: Realities Low Carbohydrate diets will result in ketosis –most cases degree of ketosis are mild –most cases there is some appetite suppression –in some cases, there will be ketoacidosis and electrolyte imbalance - need for physician supervision

37. The High Protein/Low Carbohydrate Diets: Conclusions High protein diets will result in short term weight loss Long term effectiveness is very questionable Long term effect on health is a concern

38. A Randomized Trial of a Low- Carbohydrate Diet for Obesity. Foster et al. NEJM 348:2082-90 (2003) 66 obese men and women (BMI=34) Randomly assigned to diets for 1 year Professional contact minimal to replicate approach used by most dieters

39. Weight loss (%BW loss) 3 months Low fat:2.7% Low cho:6.8% (p=0.001) 6 months Low fat:3.2% Low cho:7.0% (p=0.02) 12 months Low fat:2.5% Low cho:4.4% (ns)

40. Changes in risk factors Improved in low CHO diet groups –Serum Triglycerides –HDL-cholesterol No difference between low CHO and low Fat diet groups –Blood pressure (ns) –LDL-cholesterol NS (but lower in low fat at 3 mo., mean lower at 12 months) –Insulin sensitivity (ns)

41. Drop-out rate: –Low fat:43% –Low cho:39% Reported adverse reactions higher in Low CHO group –GI problems (diarrhea/constipation) –Bad breath –Fatigue/weakness –headache

42. Low-Carb Diets Summary of Long-term studies What the research shows: –Short-term outcomes 6 month studies –Better weight loss –Improved plasma TG and HDL-C –drop-out rate significant in both LC and LF –Adverse effects greater in LC –Long-term outcomes 1 year studies – weight loss no better than low fat group – still improved plasma TG and HDL-C –drop out rate significant in both groups –LC eating more CHO than recommended, low SFA, high MUFA –LF eating more FAT than recommended

43. Dietary Means to a Healthy Weight The Carbohydrate ‘Restrained’ Diets Characteristics Lower in CHO than Dietary Guidelines but higher than Low Carb diets (~40% CHO, 30%FAT, 30%PRO) Low glycemic index foods encouraged Monounsaturated fats encouraged Examples –Zone Diet, South Beach Diet What the research shows: –Little research available on these diets

44. Very Low Calorie Diets VLCDs Characteristics –400-800 Cal/d –Generally semi-synthetic beverages –‘high protein’ (50-100g/d) –Very low fat –Low to moderate CHO –Expensive

45. Very Low Calorie Diets VLCDs Must be Medically Supervised –Generally safe Minor side effects –Fatigue –Constipation or diarrhea –Nausea/dizziness –Cold intolerance Possible significant side effects –Gall stones –Electrolyte imbalances

46. Very Low Calorie Diets VLCDs Patient Criteria –BMI > 30 –BMI= 27-30 with medical complications Contraindications –Pregnancy –Children –history of dysrhythmia of heart gall stones renal dysfunction

47. Very Low Calorie Diets VLCDs Short term outcome –Rapid high quality weight loss 30-35 kg in 25 weeks –Reduction in health risks Long term success –No more (or less) successful than other treatments –Maintenance program (diet, behavior, exercise) critical for success

49. Guidelines for Identifying Weight Loss Fraud Claims easy, large, fast weight loss eat all you want, no exercise uses quackery terms gets rid of “cellulite” relies on undocumented cases

50. Guidelines for Identifying Weight Loss Fraud Claims government approval gives no or incomplete scientific references cures everything promotes use of unproven aids/gadgets –equipment –supplements

51. Guidelines for Identifying Weight Loss Fraud Makes claims about “problems associated with combining certain foods in the same meal” Describes diet as being opposed by the the established medical community Distributed exclusively by mail order, internet, 800 phone, pyramid sales organization

52. Remaining Fall 2002 Schedule 12/2 –Hi PRO/low CHO diets –VLCD – see web notes and WIN web reading –Exercise and weight loss –BM/assessment assignment due Turn in: –your BM records –SOAP notes for your client 12/4 –Pharmacological approaches to weight loss 12/6 –Surgical methods for weight loss 12/13 –8:30-10 – Final Exam

53. RCT – Atkin’s Diet E. Westman, Duke Univ. presented at 2002 AHA annual meeting Funded by R. Atkins Foundation 120 overweight subjects –Randomized Atkins diet AHA step 1 diet (US Dietary Guidelines) –6 months

54. RCT – Atkin’s Diet What does this mean? Greater adherence due to novelty? –ADA step 1 diet not much different than typical diet Don’t ignore 100’s of studies of CHD dangers of high SFA/chol diets –Based primarily on stable weight This is a short term study –Long term weight loss success –Effect of weight maintenance on blood lipids Provocative, but…wait and see!

55. Extra Credit Opportunity Replaces the 25pt Eating Behaviors Project Worth 5 extra credit points Write a 2+ page commentary on the USA Today article: –Kids need school's help to get healthy http://www.usatoday.com/news/health/2003-05-19-fitkids- usat_x.htmhttp://www.usatoday.com/news/health/2003-05-19-fitkids- usat_x.htm To get all 5 points, your commentary must be: –Thoughtful (and realistic) –Well organized –Well written –typed

56. Characteristics of a Healthy Diet Low Fat, Low Saturated Fat –reduces CHD, Hpt, cancer risks –lowers caloric density and may reduce food intake reducing dietary fat alone without reducing calories is insufficient

57. Characteristics of a Healthy Diet High in Fiber –reduces CHD & cancer risks –reduces caloric density Low in Sugar –reduces caloric density –often associated with high fat foods

58. Characteristics of a Healthy Diet Moderation in salt and alcohol –reduces hpt, CHD, cancer risks –alcoholic beverages high caloric density

59. Findings RCT – Atkin’s Diet AHA step 1 diet –Wt loss = 20 lbs –LDL-C = no change –TG = 22% drop –HDL-C = unchanged Atkins Diet –Wt loss = 31 lbs –LDL-C = no change –TG = 49% drop –HDL-C = 11% increase –Fewer drop-outs

60. A Low-Carbohydrate as Compared with a Low-fat Diet in Severe Obesity. Samaha et al. NEJM 348:2074-81(2003) 132 severely obese (BMI=43) Randomly assigned to low-CHO or low- Fat diets for six months Weight loss at 6 months: –Low-fat: 1.9kg –Low-CHO: 5.8kg

61. Triglyceride change –Low fat:-7mg/dl –Low cho:-38 mg/dl (p<.001) LDL-C –Low fat:+ 3mg/dl –Low cho:+ 5mg/dl (ns) HDL-C –Low fat:- 1mg/dl –Low cho0 mg/dl (ns) Hemoglobin A1c –Low fat: 0% –Low cho:-0.6% (p=.06)

62. Dietary changes –Caloric intake Low fat:-271 Cal/day Low cho:-460 Cal/day (ns) –Fat intake (% of calories) Low fat: 33% to 33% Low cho: 33% to 41% (p<.001) Drop-out rate at 6 months –Low fat:47% –Low cho:33% (ns)