Weight Management

1
Weight Management
2
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

3
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.

4
Why Diets Dont 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

5
Why Diets Dont 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

6
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

7
Weight Gain in Adulthood

• Weight gain is common from ages 25-44
• 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

8
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

9
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

10
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 2700-3500 kcal to
  lose a pound per week

11
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
12
Sound Weight Loss Program

• Rate of loss
• Flexibility
• Intake
• Behavior Modification
• Overall Health

13
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

14
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

15
Behavior Modification

• Modify problem (eating) behaviors
• Chain-breaking
• Stimulus control
• Cognitive restructuring
• Contingency management
• Self-monitoring

16
Chain-Breaking

• Breaking the link between two behaviors
• These links can lead to excessive intake
• Snacking while watching T.V.

17
Stimulus Control

• Alternating the environment to minimize the
  stimuli for eating
• Puts you in charge of temptations

18
Cognitive Restructuring

• Changing your frame of mind regarding eating
• Replace eating due to stress with walking

19
Contingency Management

• Forming a plan of action in response to a
  situation
• Rehearse in advance appropriate responses to
  pressure of eating at parties

20
Self-Monitoring

• Tracking foods eaten and conditions affecting
  eating
• Helps you understand your eating habits

21
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

22
Weight Loss Triad
Control Energy Intake
Control Problem Behaviors
Perform Regular Physical Activity
23
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

24
Diet Drugs Amphetamine (Phentermine)

• Prolongs the activity of epinephrine and
  norepinephrine in the brain
• Decreases appetite
• Not recommended for long term use (dependency)

25
Sibutramine (Meridia)

• Enhances norepinephrine and serotonin activity
• Decreases appetite (eat less)
• Not recommended for people with HTN

26
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

27
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

28
Bariatric Surgery

• An increasingly popular option for severely obese
  people who are unlikely to lose weight through
  conventional means
• Cost 20-35000
• Some insurers cover it

29
Candidates for Bariatric Surgery

• BMI of 40 or moreabout 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

30
Bariatric Surgery

• Restrictive
• Malabsorptive
• Combination restrictive/malabsorptive

31
Restrictive Surgery Adjustable Gastric Band
32
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

33
Restrictive/Malabsorptive Roux en Y
34
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.

35
Low Carbohydrate Diets (Past)

• The Scarsdale Medical Diet
• The Drinking Mans Diet
• Dr. Atkins Diet Revolution
• The Marine Corps Diet
• The Last Chance Diet
• The Mayo Clinic Diet

36
Low Carbohydrate Diets (Recent)

• Enter the Zone
• Dr. Bob Arnots 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

37
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

38
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

39
Atkins Diet

• Supplements are recommended for everyone a
  multivitamin lecithin L-glutamine chromium
  piccolinate
• Can purchase supplements from the Atkins
  Institute
• Recommends exercise

40
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

41
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

42
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

43
Atkins Sample menu OWL

• B Western omelet 3 ounces tomato juice 2 carbo
  grams of bran crispbread decaf coffee or tea
• L Chefs 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

44
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 foods potential impact on body
  weight

45
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

46
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

47
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

48
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

49
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

50
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

51
High Carbohydrate Low Fat Diets

• The Pritikin Weight Loss Breakthrough
• Eat More Weigh Less (Dean Ornish)
• American Heart Association diets
• NHLBI TLC diet

52
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

53
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

54
Research on Macronutrient Mix in Weight Loss Diets
55
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 carb/day) plus nutritional supplementation
  exercise recommendation and group meetings or
  low-fat diet (deficit of 500-1000 kcal/d) plus exercise
  recommendation and group meetings

Yancy W. S. et. al. Ann Intern Med
2004140769-777
56
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)

57
Expected mean body weight over time by diet group
Yancy W. S. et. al. Ann Intern Med
2004140769-777
58
Low Carb vs. Low Fat

• Low carb group had increases in HDL-C (5.5
  mg/dL vs. -1.6 mg/dL P
• 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
2004140769-777
59
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 500 cals/day with

• Stern L. et. al. Ann Intern Med 2004140778-785

60
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 2004140778-785

61
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 2004140778-785
62
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

63
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

64
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

65
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

66
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

67
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!

68
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

69
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

70
Diet Quality of Popular DietsCSFII Data Healthy
Eating Index
71
Energy Intake of Adults on Popular DietsCSFII
DATA
72
BMI of Adults on Popular DietsCSFII DATA
73
BMI Vegetarians/Non VegetariansCSFII DATA
74
Energy Intake Vegetarians/ Non-Vegetarians
(CSFII DATA)
75
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

76
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

77
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

78
NWCR Weight Loss Methods
79
NWCR Weight Maintenance Methods
80
Underweight is Also a Problem

• 15-25 below healthy weight or BMI of
• 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

81
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