Nutrition Interventions in the
Treatment of Obesity
Dana White, MS, RD, LDN
October 25, 2013
Outline
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Problem of Obesity
Energy Balance Equation
Nutrition Interventions
Energy Density
 Meal Frequency
 Role of Protein
 Meal Replacement Products
 Planning
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Take home messages
Problem of Obesity

Data from National Health and Examination
Survey 2009-2010 (1):
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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
Energy Balance Equation
Graphic: Eat Well, Live Well. A Healthy Way of Life
Nutrition Manual. LifeTime Fitness, 2011.
8% TEF
60-75%
RMR
Thermic Effect of Food
Physical Activity
Resting Metabolic Rate
17-32% PA
Segal KR et al. Am J Clin Nutr. 1984;40:995-1000
NUTRITION INTERVENTION 1
EAT MORE, WEIGH LESS
Trying to Reduce your Calories?
Energy Density of Foods
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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
Weight of Food
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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.
Energy Density Food Examples
160 calories /
34g = 4.7
Energy Density

Influenced by the consumption of fruit,
vegetables, fiber and fat.
1. Fruits and vegetables = ↑ water content.
Water adds weight but not kcal to foods.
2. Fiber- provides volume, takes longer to
digest helping you to feel full on fewer kcal
3. Lower Fat choices - 9 kcal/g versus 4 kcal/g
for CHO and Pro.
Energy Density Food Examples
≡
Energy Density Food Examples
≡
Energy Density Food Examples
The DASH Diet
(Dietary Approaches to Stop Hypertension)
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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?
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CHO: 55%, Fiber: 30g, Pro: 18%
↓ Sodium (<3000mg/d, best BP results with 1500mg/d)
1.
2.
3.
4.
http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf
Sacks FM et al. Clin Card 1999;22(SIII), III-6-III-10.
Azadbakht L et al. Diabetes Care 2011;34)(1):55-57.
Miller ER et al. Hypertension, 2002;40:612-618.
DASH Diet
Rich in magnesium, potassium, and calcium
Plenty
Fruits
Vegetables
8-12/day
Low-Fat Dairy
3/day
Whole Grain
Products
6-8/day
Lean Meat, Fish,
Poultry
3-6oz/day
Sweets
Nuts
3-6/week
Sugar-Containing
Beverages
Limit (<5/week)
Red Meats
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)
∆ Body Weight (kg)
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0
-1
Weight (kg)
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Advice Group
Weight Loss
Group
Weight Loss
+DASH
-1.1
-2
-3
-4
-5
-6
-5.1
-6.1
-7
p<0.001
Ledikwe JH, et al. Am J Clin Nutr 2007; 85:1212-21.
PREMIER Trial Results
• Greatest
reduction in
energy intake
seen), BUT, total
weight of food
increased
(+>250g). p<0.001
Total Weight of Food (g)
1300
Food (g)
1200
1100
1305g
(+250g).
1000
900
1021g
1011g
Advice Group
Weight Loss Group
800
Weight Loss +
DASH Group
• 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.
PREMIER TRIAL RESULTS
1600
1560 kcal
1400
1200
1476kcal
1120g
1396kcal
1215g
998g
1000
800
600
Mean kcal intake
↓ by ~500 kcal/d
AND mean
weight of food ↑
by ~300g/d (2/3
pound) from
baseline.
400
Food weight (g)
Food intake (kcal)
200
0
Increase or
small decrease
in ED
Medium
Largest decrease
decrease in ED
in ED
Ledikwe JH, et al. Am J Clin Nutr 2007; 85:1212-21.
Energy Density and Weight Loss
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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.
How do we help patients do this?
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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 dishespastas, casseroles, soups, stir fry
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Add more whole fruits
Apples, oranges, grapes, pears,
melons, pears, berries, etc
 Have w/ a protein source
 Avoid juice
Vegetables
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Protein
Starches
How do we help patients do this?
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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
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Pasta Makeover
Fettucini
Alfredo
Whole grain pasta
with marinara sauce
1 cup = 415 kcals
ED: 2.08
Whole grain pasta
w/ vegetables in a
marinara sauce
1 cup = 140 cals
ED: 0.86
1 cup = 222 kcal
ED: 1.0
Which would fill you up more?
=
NUTRITION INTERVENTION 2
MEAL FREQUENCY
Meal Frequency
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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:
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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
Meal Frequency
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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
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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.
NUTRITION INTERVENTION 3
PROTEIN POWER
How Much Protein?
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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.
Evans et al. Nutr & Metab. 2012, 9:55
Wycherley et al. Am J Clin Nutr. 2012;96(6):1281-98
Halton T, Hu F. Jour Amer. Coll Nutr. 23:5;373-385
Role of Protein in Weight Loss
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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
Higher Protein, Low Fat Diets
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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
Protein Sources
Include with each meal and snack
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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
Helping Patients Incorporate Protein
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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
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NUTRITION INTERVENTION 4
MEAL REPLACEMENT
PRODUCTS
What is a MRP?
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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.
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Examples: Liquid meals,
meal bars, calorie controlled
packaged meals
MRPs and Weight Loss
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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.
Ashley JM, et al. Arch Intern Med 2001; 161: 1599-1604.
Lowe, et al. Obesity 2013; DOI: 10.1002/oby.20582
When could you use a MRP?
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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
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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)
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When could you use a MRP?
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Trying to build consistency
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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)
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Nutrition Facts and MRPs
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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
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Frozen/pre-packaged meals
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<300 calories
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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.
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NUTRITION INTERVENTION 5
BE ONE STEP AHEAD
Planning
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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?
TAKE HOME MESSAGES
In Summary
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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
Other Factors …
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Self-monitoring – calorie/exercise tracking apps
Sleep – at least 6-8 hours/night
Exercise
Accountability
Thank you!