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Transcript
Weight Management
The War on Weight



25% of men and
40% of women are
trying to lose
weight
Approximately 45
million Americans
diet each year
Nationwide, 55
million Americans
are actively trying
to maintain their
weight
The War on Weight



Consumers spend about $30 billion per year
on weight related items. This includes diet
sodas, diet foods, artificially sweetened
products, appetite suppressants, diet books,
videos and cassettes, medically supervised
and commercial programs, and fitness clubs.
Spending on weight loss programs is
estimated at $1 to 2 billion per year.
U.S. food manufacturers are estimated to
have spent $7 billion on advertising of
highly processed and packaged foods in
1997.
Why Diets Don’t Work

Obesity is a chronic disease
– Treatment requires long-term lifestyle
changes

Dieters are misdirected
– More concerned about weight loss than
healthy lifestyle
– Unrealistic weight expectations
Why Diets Don’t Work
Body defends itself against weight loss
 Thyroid hormone concentrations
(BMR) drop during weight loss and
make it more difficult to lose weight
 Activity of lipoprotein lipase increases
making it more efficient at taking up
fat for storage
Weight Cycling





Typically weight loss is not maintained
Weight lost consists of fat and lean
tissue
Weight gained after weight loss is
primarily adipose tissue
Weight gained is usually more than
weight lost
Associated with upper body fat
deposition
Weight Gain in Adulthood




Weight gain is common from ages 2544
BMR decreases with age
Inactive lifestyle
Goal: not to gain more than 10-16
pounds more than your weight on
reaching the age of 21
Changes in Body Composition



Fluid is usually the first weight lost
Loss in lean body tissue means
lowering the BMR
Weight loss represents a combined
loss of lean body tissue and fat
Lifestyle Vs. Weight Loss




Prevention of obesity is easier than curing
Balance energy in(take) with energy
out(put)
Focus on improving food habits
Focus on increased physical activities
What It Takes To Lose a
Pound



Body fat contains 3500 kcal/lb
Fat storage (body fat plus supporting
lean tissues) contains 2700 kcal/lb
Must have an energy deficit of 27003500 kcal to lose a pound per week
Do the Math
To lose one pound, you must create a deficit of
2700-3500 kcal
So to lose a pound in 1 week (7 days), try cutting
back on your kcal intake and increase physical
activity to create a deficit of 400-500 kcal per day
- 500 kcal x 7 days = - 3500 kcal = 1 pound of weight loss
day
week
in 1 week
Sound Weight Loss
Program





Rate of loss
Flexibility
Intake
Behavior Modification
Overall Health
Cutting Back






1200-1500 kcals per day
Control calorie intake by being aware
of kcal and fat content of foods
“Fat Free” does not mean “Calories
Free” (or “All You Can Eat”)
Read food labels
Estimate kcal using the exchange
system
Keep a food diary
Regular Physical Activity




Fat use is enhanced with regular
physical activity
Increases energy expenditure
Duration and regularity are important
Make it a part of a daily routine
Behavior Modification






Modify problem (eating) behaviors
Chain-breaking
Stimulus control
Cognitive restructuring
Contingency management
Self-monitoring
Chain-Breaking


Breaking the link between two
behaviors
These links can lead to excessive
intake
Snacking while watching T.V.
Stimulus Control


Alternating the environment to
minimize the stimuli for eating
Puts you in charge of temptations
Cognitive Restructuring


Changing your frame of mind
regarding eating
Replace eating due to stress with
“walking”
Contingency Management


Forming a plan of action in response
to a situation
Rehearse in advance appropriate
responses to pressure of eating at
parties
Self-Monitoring


Tracking foods eaten and conditions
affecting eating
Helps you understand your eating
habits
Weight Maintenance

Prevent relapse
– Occasional lapse is fine, but take charge
immediately
– Continue to practice newly learned behavior
– Requires “motivation, movement, and
monitoring”

Have social support
– Encouragement from friends/ family/
professionals
Weight Loss Triad
Control Energy
Intake
Perform Regular
Physical Activity
Control “Problem”
Behaviors
Dieting Can Be Hazardous
To Your Health
Weight regained consists of a
higher percentage of body fat than
before
 Less healthy than before dieting
 Weight loss diet should not be
considered unless you are
committed and motivated

Diet Drugs: Amphetamine
(Phentermine)



Prolongs the activity of epinephrine and
norepinephrine in the brain
Decreases appetite
Not recommended for long term use
(dependency)
Sibutramine (Meridia)



Enhances norepinephrine and
serotonin activity
Decreases appetite (eat less)
Not recommended for people with HTN
Orlistat (Xenical)






Inhibits fat digestion
Reduces absorption of fat in the small
intestine
Fat is deposited in the feces, causing
side effects
Must control fat intake
Malabsorption of fat-soluble vitamins
Supplements needed
Very Low-Calorie Diets
(VLCD)







Recommended for people >30% above
their healthy weight
400-800 kcal per day
Low carbohydrates and high protein
Causes ketosis
Lose ~3-4 pounds a week
Requires careful physician monitoring
Health risks includes cardiac problems
and gallstones
Bariatric Surgery



An increasingly popular option for
severely obese people who are
unlikely to lose weight through
conventional means
Cost: $20-$35,000
Some insurers cover it
Candidates for Bariatric
Surgery



BMI of 40 or more—about 100 pounds
overweight for men and 80 pounds for
women
BMI between 35 and 39.9 and a serious
obesity-related health problem such as type
2 diabetes, heart disease, or severe sleep
apnea
Willingness to make associated lifestyle
changes
Bariatric Surgery



Restrictive
Malabsorptive
Combination restrictive/malabsorptive
Restrictive Surgery:
Adjustable Gastric Band
Diet After Surgery



After restrictive surgeries, patients can
only eat ½ cup to 1 cup of food at a
time
Foods often must be soft and chewed
thoroughly
Patients who eat too fast or the wrong
kinds of food may have vomiting
Restrictive/Malabsorptive:
Roux en Y
Diet Books: Big Business



The original Dr. Atkins Diet Revolution is one
of the ten best selling books of all time
Dr. Atkins New Diet Revolution is still #14
on the NYT paperback advice bestseller list
(11/04) having been on the list for years
The South Beach Diet has been on the NYT
hardcover advice bestseller list for 81
weeks, and is currently #4.
Low Carbohydrate Diets
(Past)






The Scarsdale Medical
Diet
The Drinking Man’s
Diet
Dr. Atkins Diet
Revolution
The Marine Corps Diet
The Last Chance Diet
The “Mayo Clinic” Diet
Low Carbohydrate Diets
(Recent)








Enter the Zone
Dr. Bob Arnot’s Revolutionary Weight Control
Program
Protein Power
Sugar Busters
Dr. Atkins New Diet Revolution
Feed Your Kids Well (Atkins for Kids)
The Fat Flush Plan (Gittleman)
The South Beach Diet
Atkins Diet Premise


Stabilizes insulin production by limiting
carb intake. This forces the body from
glucosis into lipolysis, thus ketones are
burned as the primary energy source.
This results in a metabolic advantage
of low carbohydrate: dieters can lose
weight while eating more calories
Atkins Diet



“Induction Phase”: 2 weeks, 20 g
carb/day
Eliminate fruit, bread, grains, starchy
vegetables, dairy products except cheese,
cream, butter
20 g carb: 3 cups salad greens, or 2 cups
salad plus 2/3 cups cooked vegetables
such as asparagus, summer squash, green
beans
Atkins Diet



Supplements are recommended for
everyone: a multivitamin, lecithin, Lglutamine, chromium piccolinate
Can purchase supplements from the
Atkins Institute
Recommends exercise
Atkins Phase 2: OWL





“Ongoing weight loss phase” or “Owl.”
Add carbohydrate at a rate of 5 grams
a day until weight loss stops
This is the CCLL: critical carbohydrate
level for losing
May be 45, or 33, or 19 grams/day
Continue at this level until desired
weight is reached
Atkins Maintenance



Determine CCLM: critical carbohydrate
level for maintenance (the level at
which weight stabilizes)
Most will stabilize at 25 to 90
grams/day
If weight gain occurs, return to
induction diet
Atkins- Sample Menu
Phase 1



B: scrambled eggs and ham, butter,
decaffeinated coffee or tea
L: Bacon cheeseburger, no bun, small
tossed salad, selzer water
D: shrimp cocktail with mustard and
mayo, clear consomme, steak, roast,
fish or fowl, tossed salad, diet gelatin
with whipped cream, sf beverage
Atkins: Sample menu
OWL



B: Western omelet, 3 ounces tomato
juice, 2 carbo grams of bran
crispbread, decaf coffee or tea
L: Chef’s salad with ham, cheese,
chicken and egg; zero carbohydrate or
oil and vinegar dressing, iced herbal
tea
D: Seafood salad, poached salmon,
2/3 cup vegetable from permitted list,
half cup of strawberries in cream
South Beach Diet Premise




“Addiction” to carbs is a psychological need
for comfort food and is likely a real,
physiological phenomenon
Eating bad carbs leads to cravings for more
which is “ultimately responsible for our
obesity epidemic”
States that Atkins may limit carbs too
severely
Stresses glycemic index as the biggest
determinant of a food’s potential impact on
body weight
South Beach Diet: Phase 1
(2 weeks)






Carbs limited to low-carb vegetables, salads, 1%
milk, fat-free buttermilk, nonfat yogurt.
Proteins: unlimited lean meats, poultry, fish, low fat
cheese, tofu
Nuts included, but limited
“Good” fats including olive, canola oils
Sugar-free hard candies, diet gelatin, sugar subs
NO fatty meats, starchy vegetables like corn,
potatoes, carrots, no fruits, no grains, no alcohol
South Beach: Sample Day
Phase 1






B: 6 oz tomato juice, 1/4-1/2 cup liquid egg
substitute, decaf coffee or tea, non-fat milk,
sugar substitute
snack: 1-2 turkey roll ups
L: SB chopped salad with tuna, sf gelatin
snack: celery, 1 wedge Laughing Cow Light
Cheese
D: baked chix breast, roasted eggplant and
peppers, salad, lo sugar dressing
Dessert: Mocha Ricotta Creme
South Beach Diet: Phase 2



Reintroduces most fruits, whole grains (sparingly)
including popcorn, legumes such as pinto beans,
starchy vegetables such as peas, carrots and sweet
potatoes, flavored nonfat yogurt, semisweet or
bittersweet chocolate, wine
Still forbidden: white flour and products made from
it including breads, cookies, pasta; potatoes, white
rice, corn; fruits including bananas, canned fruit,
pineapple, raisins, watermelon
Dieters stay in this phase until goal weight achieved
South Beach: Sample Day
Phase 2





B: 1 cup blueberries; 1 scrambled egg w/ salsa;
oatmeal mixed with 1 cup nonfat milk, sprinkled
with cinnamon and walnuts; coffee or tea
Snack: 4 oz non-fat sugar-free yogurt
L: Tuna salad w/ celery, mayo, tomato, onion in
whole wheat pita
Snack: 1 part-skim mozzarella cheese stick
D: Pan roasted steak and onions, South Beach
salad, steamed broccoli; chocolate-dipped
strawberries
South Beach Diet: Phase
3



Maintenance- no foods are forbidden
Continue to limit high carb, refined or
heavily processed foods.
Return to earlier phase if weight gain
occurs
South Beach vs Atkins
Phase 1




Atkins
Proteins: All meats, poultry,
fish, shellfish, eggs, cheese
are unlimited
Fats: vegetable oils, butter,
mayonnaise, heavy cream,
bacon
Vegetables: 3 cups salad or
2 cups salad and 2/3 cup
low carb vegetables
NO: artificial sweeteners,
margarine, fruits, grains,
breads, starchy vegetables,
dairy, alcohol





South Beach
Proteins: Lean beef, pork,
skinless poultry, low fat
cheese, seafood, eggs
Fats: Canola and olive oil
Vegetables: salad greens,
beans, tomatoes, cabbage,
summer squash, broccoli, all
low carb are unlimited
Dairy: Fat free or 1% milk or
yogurt
NO: fatty meat, high fat
cheese; fruits, grains, breads,
starchy vegetables, butter,
margarine, alcohol
High Carbohydrate Low
Fat Diets




The Pritikin Weight Loss Breakthrough
Eat More, Weigh Less (Dean Ornish)
American Heart Association diets
NHLBI TLC diet
High Carb Low Fat Diets


Rationale: diet is high in bulk and
fiber, low in calorie density producing
early satiety and weight loss
Description: 50-75% carbohydrate
calories, relatively less meat, fish, fats
and oils, more grains, cereals, breads,
fruits, vegetables
Sample Menu: High Carb
Low Fat





B: 1 cup blueberries; oatmeal mixed with 1
cup nonfat milk, sprinkled with cinnamon
and walnuts; coffee or tea
Snack: 4 oz non-fat sugar-free yogurt
L: Vegetarian vegetable soup, fresh orange,
nonfat yogurt
D: Grilled salmon with yogurt-dill sauce,
bulgur with raisins, steamed broccoli;
strawberries over angelfood cake
Snack: air popped popcorn
Research on Macronutrient
Mix in Weight Loss Diets
Low Carb vs Low Fat Diet




Objective: Compare effects of a low-carb, ketogenic
diet (Atkins) with those of a low-fat, low chol,
reduced calorie diet
Design: Randomized, controlled
Subjects: 120 overweight, hyperlipidemic
volunteers
Intervention: Low carb diet (initially <20 g
carb/day) plus nutritional supplementation, exercise
recommendation, and group meetings or low-fat
diet (<30% energy from fat, <300 mg chol, deficit
of 500-1000 kcal/d) plus exercise recommendation
and group meetings
Yancy, W. S. et. al. Ann Intern Med 2004;140:769-777
Low Carb vs Low Fat Diet




Measurements: body weight, body composition,
fasting serum lipid levels and group meetings
Results: 76% of the low-carb group and 57% of
the low-fat group completed the study. At 24
weeks weight loss was greater in the low-carb
group (12.9%) than in the low-fat group (6.7%)
Pts in both groups lost more fat mass (-9.4 kg low
carb, -4.8 kg low-fat) than fat free mass (-3.3 kg vs
-2.4 kg)
Low carb diet subjects had > decreases in serum
triglycerides (-74.2 mg.dL vs. -27.9 mg/dL)
Expected mean body weight over time, by diet group
Yancy, W. S. et. al. Ann Intern Med 2004;140:769-777
Low Carb vs. Low Fat

Low carb group had > increases in HDL-C (5.5
mg/dL vs. -1.6 mg/dL P<0.001)




Changes in LDL-C were not significant
Low carb group had greater participant retention
and greater weight loss over 24 weeks
Minor adverse effects were more frequent in the
low-carb diet group
Limitations: Effects of the low-carb diet and of the
nutritional supplements could not be separated.
Participants were healthy and were followed for
only 24 weeks.
Yancy, W. S. et. al. Ann Intern Med 2004;140:769-777
Low carb vs. conventional
1 year follow up



Objective: Review the 1-year outcomes of two
groups randomized to these diets
132 obese adults, BMI 35 or greater; 83% had
diabetes or metabolic syndrome
Participants were counseled to either restrict
carb intake to < 30g/day or reduce calories by
500 cals/day with <30% of cals from fat
Stern, L. et. al. Ann Intern Med 2004;140:778-785
Low carb vs. conventional
1 year follow up




By 1 year, mean weight change for persons on the
low carb diet was -5.1 +/- 8.7 kg compared with 3.1 +/- 8.4 kg for persons on a conventional diet.
Differences were not significant (P= 0.20)
Triglycerides decreased more on low carb diet, HDL
levels decreased less, HbA1c improved more
Changes in other lipids (LDL, total-C) and insulin
sensitivity did not differ between groups
Limitations: 34% drop out rate, suboptimal dietary
adherence; relatively small net weight loss in both
groups
Stern, L. et. al. Ann Intern Med 2004;140:778-785
Comparison of mean weight loss in kg between participants on the
conventional diet and participants on the low-carbohydrate diet at 6 months
(n = 118) and at 1 year (n = 126)
Stern, L. et. al. Ann Intern Med 2004;140:778-785
Low Carb vs. Conventional Diet
Outcomes



Between 6 months and 1 year, persons in
the low carb group began to regain weight
while persons on the conventional diet
continued to lose weight
By 6 months, there was no significant
difference in weight loss between the two
groups
Intake data suggest that differences in
weight loss, where they exist, are the result
of differences in calorie intakes, not a
metabolic advantage of low carb
Summary: High Pro Low
Carbohydrate Diets

Pros:
– High pro low carb diets appear to produce
greater short term weight loss
– In studies, there was a lower dropout rate
with high pro low carb diets
– High pro low carb diets produced favorable
lipid changes
Summary: High Pro Low
Carbohydrate Diets

Concerns
– long term safety (effects of high pro diet on kidney
function, lack of phytochemicals, association of ↑ red
meat and ↑ sfa intake with ↑ cancer)
– questionable rationale (protein stimulates insulin
release)
– difficult to follow long term
– epidemiological evidence shows vegetarians are
slimmer
– at risk nutrients: calcium, potassium, vitamin C,
vitamin D
High Carb Low Fat Diets

Pros
– Fits most major dietary guidelines including
U.S. Dietary Guidelines, TLC diet, AHA diet;
high in fiber and plant foods associated
with health benefits
– Epidemiological evidence associates high
carb low fat diets with lower rates of heart
disease, cancer, obesity
– Consistent with pattern reported by
successful dieters in the National Weight
Control Registry
Summary: High Carb Low
Fat Diets

Cons
– Produces more gradual weight loss than
high protein diets; dieters become
discouraged
– Very high carb low fat diets associated
with unfavorable lipid changes (may need
to choose whole grains, replace some
carb with MFA)
– At risk nutrients: B12, D, E, Zinc
Weight Loss By Any Method
Will:



Reduce blood lipid levels including TC,
LDL-C, HDL-C, and Tg
Improve glycemic control
Reduce blood pressure
Especially during active weight loss!
Low Carb vs Low Fat



Weight loss is caused by a deficit in
calories, not a metabolic advantage of
one over the other
Persons with the greatest calorie
deficit lost the most weight
A high protein diet may offer some
advantages, perhaps in simplicity,
limiting options, or increased satiety
Low Carb vs Low Fat



Many VLCD programs offer a high
protein, low carb, low fat approach
People should be offered options in
weight management
The major issue in diet success is how
persons plan to keep the weight off
Diet Quality of Popular
Diets
CSFII Data: Healthy Eating Index
80
70
60
50
40
HEI SCORE
30
20
10
0
LOW CHO
MOD CHO
HIGH CHO
Energy Intake of Adults on
Popular Diets
CSFII DATA
2200
2150
2100
2050
2000
Energy (kcal)
1950
1900
1850
1800
1750
LOW CHO
MOD CHO
HIGH CHO
BMI of Adults on Popular
Diets
CSFII DATA
28
26
24
22
20
MEN
WOMEN
18
16
14
12
10
LOW CHO
MOD CHO
HIGH CHO
BMI Vegetarians/Non
Vegetarians
CSFII DATA
27
25
23
Men
Women
21
19
17
15
VEG
NON-VEG
Energy Intake Vegetarians/
Non-Vegetarians
(CSFII DATA)
2500
2000
1500
Energy (kcal)
1000
500
0
VEG
NON-VEG
NHLBI Recommendations:
Diet Therapy for Weight
Mgmt



Low calorie diets are recommended for
weight loss in overweight and obese
persons
Reducing fat as a part of LCD is a
practical way to reduce calories.
Plan for a deficit of 500-1000 kcal/day
for weight loss of 1-2 lb/wk
NHLBI Recommendations:
Physical Activity




Physical activity modestly contributes
to weight loss, may decrease
abdominal fat, increases
cardiorespiratory fitness
VERY important for wt maintenance
Initially 30-45 minutes moderate
activity, 3-5 days a week
Long term: 30 minutes + of moderate
intensity activity on most/all days
National Weight Control
Registry



Self-selected data base of people who
have lost at least 30 lb and kept it off
at least one year
Published data on 784 persons, 80%
female, 97% white, 56% with college
degrees, mean age 45 years
Had average maximum BMI of 35;
most had attempted wt loss numerous
times
NWCR: Weight Loss
Methods
90
80
70
Diet and activity
Limit certain foods
Formal prog (incl RD)
Limit quantity of foods
Count calories
Limit fat kcals
Limit fat grams
60
50
40
30
20
10
0
% of Resp
NWCR: Weight
Maintenance Methods
Limits certain foods
100
90
80
70
60
50
40
30
20
10
0
Burns >1000 kcal
exercise/wk
Weighs self weekly
Limits quantity of food
Limits kcal from fat
Counts kcals
% of Resp
Counts fat grams
Underweight is Also a
Problem



15-25% below healthy weight or BMI
of <18.5
Associated with increased deaths,
menstrual dysfunction, pregnancy
complications, slow recovery from
illness/surgery
Causes are the same as for obesity but
in the opposite route
Treatment for
Underweight




Intake of energy-dense foods (energy
input)
Encourage meals and snacks
Reduce activity (energy output)
To gain a pound you need a total
excess intake of 2700-3500 kcal