Dieting, body weight and health in menopausal women

1
Dieting, body weight and health in menopausal
women

• Professor Kerin ODea AO
• Director, Sansom Institute for Health Research,
• University of South Australia

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Energy requirements as women age

• Energy balance Intake Expenditure
• As we age
• Generally become less active
• Less Lean Body Mass (muscle, bone)
• Proportionately more Fat Mass
• Lower energy requirement
• Weight loss results in loss of both LBM and FM
• Can lead to even lower resting energy
  requirements!

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Pros and Cons of weight loss in older women

• Pros
• Improvement in chronic disease risk profile
• Reduction in blood pressure, dyslipidemia,
  metabolic syndrome
• If weight loss is maintained
• Reduction in risk of a number of age-related
  conditions
• Type 2 diabetes
• CVD

• Cons
• Bone loss
• Loss of muscle mass
• Lower energy requirements
• Rebound weight gain

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How to optimise the outcome??

• Minimise the risk of bone and muscle mass loss
• Important role of physical activity
• Aerobic
• Resistance
• Important role of the type of diet
• Adequate Ca and protein
• Importance of adequate vitamin D
• Outdoor activities

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The big challenges in effective weight loss
interventions

• Achieving and maintaining weight loss
• How much weight loss?
• At least 5
• Which diet?
• The DPP in the US and the DPS in Finland both
  focussed on reducing fat (and saturated fat) and
  increasing fibre
• Are other dietary approaches more sustainable?
• How much exercise?
• At least 30 mins/day
• Is this enough?

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Which diet?

• The DIRECT Study
• Dietary Intervention Randomised Controlled Trial
  (DIRECT)
• 322 subjects (86 men), mean age 52 yr, BMI 31
  kg/m2
• High adherence
• 95.4 at 1yr, 84.6 at 2 yr

Shai et al, New Engl J Med 359229-41, 2008
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Which diet?

• The DIRECT study a comparison of 3 healthy
  weight loss diets
• Low Fat AHA guidelines
• 1500 kcal for women, 1800 kcal for men, lt30 fat,
  lt 10 sat fat, low fat grains, legumes, fruit,
  veg
• Limit added fat and refined CHO
• Mediterranean
• 1500 kcal for women, 1800 kcal for men, 35 fat,
  olive oil, vegetable, legumes, fruit, nuts, fish,
  poultry
• Low Carbohydrate non-restricted energy
• 20g/day CHO for 2 months, then gradually
  increasing if weight loss maintained

Shai et al, New Engl J Med 359229-41, 2008
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Weight Changes during 2 Years According to Diet
Group
N Engl J Med 2008359229-41.
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Which diet?

• The least satisfactory diet was the low fat
• Difficult to adhere long term, refined CHO?
• The low-carbohydrate diet
• greatest weight loss at 6 months, with some
  rebound to 18 months
• best lipid profile
• Mediterranean diet
• weight loss at 6 months was maintained over 2 yr
• better metabolic outcomes in the sub-set with
  type 2 diabetes
• Need to repeat the study in women
• Women tended to lose more weight on the
  Mediterranean diet
• Weight loss diets can be individualised according
  to personal preference and metabolic needs

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How much exercise to maintain weight loss?

• Consensus is a minimum of 30 minutes/day most
  days 150 min/week
• Recent data suggests much more is needed to
  maintain weight loss
• People need to burn gt2000 calories (gt8.4 MJ) per
  week to maintain diet-induced weight loss over
  the long term
• Brisk walking for 1 hour per day as a minimum

Jakicic et al. Arch Intern Med.
2008168(14)1550-1559
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Percentage weight loss by physical activity
categories (minutes per week) (n170)
Jakicic et al. Arch Intern Med.
2008168(14)1550-1559
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Percentage weight loss by physical activity
categories (kilocalories per week) (n170)
Jakicic et al. Arch Intern Med.
2008168(14)1550-1559
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Physical activity at baseline and at 6 and 24
months follow-up for categories of 24-month
weight loss (n170)
Jakicic et al. Arch Intern Med.
2008168(14)1550-1559
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Importance of diet AND exercise

• In order to lose weight
• Need to reduce energy intake
• Regular exercise is also of benefit
• gt1hr/day brisk walking
• In order to sustain weight loss
• Need to build exercise into daily routines and
  expend at least 2000 kcal/wk
• Change eating patterns, rather than go on a
  diet

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Physical activity used to be part of daily life!
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Key issues in relation to diet and weight loss

• ENERGY DENSITY
• Can weight loss be sustained without a low fat
  diet?
• Is the type of fat important?
• Does dietary protein increase satiety?
• Role of low GI
• Fructose
• Energy consumed as liquids

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Dieting for weight loss

• Must achieve negative energy balance
• No adverse health impacts
• Sustainable over the long term
• High palatability
• Satiety

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Energy density calories/gm Energy equivalents
100 g chocolate 2kg vegetables
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Energy density

• Huge amount of data indicating the importance of
  energy density in regulating energy intake over
  both the short and long term
• Foods highest in energy density
• Refined, processed foods high in sugars, fats,
  and low in fibre
• Assumption that low fat low energy density
• Moderate-high fat diets can also be bulky if they
  are rich in plant foods

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212 g
770 g
recipes from C. Itsiopoulos
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Can weight loss be achieved and sustained without
a low fat diet?

• If low fat diets result in reduced energy intake
  they lead to weight loss
• Low energy density is the critical factor
• ED increased by refined sugars
• Not all higher fat diets have high ED
• Mediterranean diet 40 fat, but bulky
• Not all low fat diets have a low ED
• Low fat diets rich in processed foods

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Low fat foods

• Low fat fast foods are frequently high in
  refined carbohydrates
• Sucrose, high fructose corn syrup
• Frequently marketed as health foods
• Muesli bars, fruit bars
• May have more energy and higher energy density
  than unsweetened full fat versions
• Yoghurt

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How important is the type of fat?

• Numerous studies in animals and humans indicate
  that dietary fats differ in how they are handled
  by the body
• Saturated fats are more likely to be stored (ie,
  deposited as fat)
• Unsaturated fats are more likely to be oxidised
  (ie used as an energy source)
• Oleic acid (monounsaturated) is most likely to be
  oxidised (used as an energy source)
• Polyunsaturated fats tend to be oxidised, or used
  functionally (eg, membranes, eicosanoids)

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Do high protein/low carb diets increase satiety?

• Numerous studies support this
• Skov et al, Internat J Obesity, 23 528-536,
  1999
• RCT comparing 2 low fat (30 en)
• HC, 12 protein
• HP, 25 protein
• Food provided in modules in a shop, consumed ad
  lib
• After 6 months, weight loss on both diets
• HC, 5.1 kg, 9 lost gt10 kg
• HP, 8.9 kg, 35 lost gt10 kg
• Other studies have shown meal provision, or
  detailed menu provision (as in CSIRO Diet) aids
  compliance

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How important is GI?

• Variable results, but generally positive
• Reduced postprandial insulin levels
• Association with fibre content of foods
• Reduced energy density
• Impact of refined carbohydrate?
• Sucrose and fructose have low GI
• Impact of fat in meals?
• Slows gastric emptying

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Should we be concerned about fructose?

• Unlike glucose, fructose is taken up only by the
  liver
• Efficiently converted into fatty acids and
  triglycerides
• Fructose feeding is an excellent animal model of
  insulin resistance
• Fatty liver in association with increased
  inflammation
• Obesity
• Human studies
• Linked to insulin resistance, elevated TG, weight
  gain, hypertension
• Fructose may be a particular problem for those
  with, or predisposed to, insulin resistance

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Does fructose get under the satiety radar?

• Fructose has been actively promoted because of
  its low GI
• What about its other effects metabolically?
• Short term
• Little impact on insulin or leptin
• May have little impact on satiety centrally
• Longer term
• Increase in insulin resistance
• Weight gain, dyslipidemia
• Impaired central satiety mechanisms
• Increased hunger

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Fructose as a natural sugar

• In fruit and vegetables yes
• Diluted by fibre/water
• presence of other nutrients
• Mg, K, bioactive phytochemicals
• What about fruit juice?
• Image as healthy
• Many fruit juices are very high in fructose
  (apple)

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Energy consumed as liquids

• When caloric beverages are consumed with meals
  they add to energy intake and do not affect
  perception of satiety (Della Valle et al,
  Appetite 44 187-93, 2005)
• Prospective studies in children have linked soft
  drink consumption to eight gain dose-dependently
  (Ludwig et al, Lancet, 357505-508, 2001)
• Caloric beverages do not appear to impact on
  satiety signals

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Coca Cola is fighting back!
http//www.abc.net.au/news/newsitems/200609/s17323
78.htm
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The Mediterranean-style dietprotects against
vascular disease and major cancers and possibly
also obesity and diabetes

• Rich in a wide range of plant foods green leafy
  vegetables, wild greens, herbs, nuts, pulses
• Rich in bioactive phytochemicals
• anti oxidant and anti-inflammatory
• High intake of fresh fruit
• Low intake of red meat
• Low intake of saturated fat
• Regular intake of fish and other seafood
• Low ratio of n-6/n-3 fat

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Conclusions

• Actively challenge the obesogenic environment
• Change dietary habits
• Minimise caloric beverages
• Read food labels and minimise refined CHO, as
  well as saturated fats
• Eat mostly plant foods and unrefined (bulky)
• fresh fruit, fresh and cooked vegetables,
  legumes, nuts, fish, olive oil
• Less red meat (except kangaroo!)
• Build physical activity into daily routines
• Walking, cycling, weight training

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Are humans programmed to conserve energy??
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Maybe higher energy prices will get us out of our
cars!
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Acknowledgements

• Dr Sunil Piers
• Dr Laima Brazionis
• Dr Karen Walker
• Dr Catherine Itsiopoulos