Treatments for
Overweight and Obese
Clients
Dr. David L. Gee
FCSN/PE 446
Nutrition, Weight Control & Exercise
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
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)
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
Treatment Affecting Energy
Expenditure & Losses
•
•
•
•
Increase lifestyle activity
Aerobic exercise (w/BM)
Strength training (w/BM)
Drugs (no prescription drugs
currently approved)
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
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
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
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.
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
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.
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
Food Guide Pyramid
(the New Food Pyramid has different
pyramids based on energy needs)
Energy
Intake
Grain
1600 kcal
2200 kcal
2800 kcal
6
9
11
Vegetable
3
4
5
Fruit
2
3
4
Meat (oz)
5
6
7
Fat (g)
53
73
93
Added
sugar (tsp)
6
12
18
Portion
distortion
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
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
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
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
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
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
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
Forms of Balanced
Hypocaloric Diets
• Meal Plans
– Dietary exchanges
• Weight Watchers
– Commercial Diet Packages
• Jenny Craig
• NutriSystems
– Food Supplement/Food Combos
• Slim Fast
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
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
Disadvantages of Balanced
Hypocaloric Diet
• Another “diet”
–going on, going off
• Slow rate of weight loss
–think long term
• No “magic”, no gimmick
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.
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
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
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
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)
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
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.
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
The High Protein/Low Carbohydrate Diets:
Realities
• High protein diets will result in further weight
loss if Ein < Eout
– 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
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
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
A Randomized Trial of a LowCarbohydrate 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
Weight loss (%BW loss)
• 3 months
• Low fat:
• Low cho:
2.7%
6.8% (p=0.001)
• 6 months
• Low fat:
• Low cho:
3.2%
7.0% (p=0.02)
• 12 months
• Low fat:
• Low cho:
2.5%
4.4% (ns)
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)
• Drop-out rate:
– Low fat:
– Low cho:
43%
39%
• Reported adverse reactions higher in
Low CHO group
– GI problems (diarrhea/constipation)
– Bad breath
– Fatigue/weakness
– headache
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
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
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
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
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
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
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
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
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
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
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
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!
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-fitkidsusat_x.htm
• To get all 5 points, your commentary must be:
–
–
–
–
Thoughtful (and realistic)
Well organized
Well written
typed
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
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
Characteristics of a Healthy Diet
• Moderation in salt and alcohol
– reduces hpt, CHD, cancer risks
– alcoholic beverages high caloric
density
Findings
RCT – Atkin’s Diet
• Atkins Diet
–
–
–
–
Wt loss = 31 lbs
LDL-C = no change
TG = 49% drop
HDL-C = 11%
increase
– Fewer drop-outs
• AHA step 1 diet
–
–
–
–
Wt loss = 20 lbs
LDL-C = no change
TG = 22% drop
HDL-C = unchanged
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 lowFat diets for six months
• Weight loss at 6 months:
– Low-fat: 1.9kg
– Low-CHO: 5.8kg
• Triglyceride change
– Low fat:
– Low cho:
-7mg/dl
-38 mg/dl (p<.001)
• LDL-C
– Low fat:
– Low cho:
+ 3mg/dl
+ 5mg/dl (ns)
• HDL-C
– Low fat:
– Low cho
- 1mg/dl
0 mg/dl (ns)
• Hemoglobin A1c
– Low fat:
– Low cho:
0%
-0.6% (p=.06)
• Dietary changes
– Caloric intake
• Low fat:
• Low cho:
-271 Cal/day
-460 Cal/day (ns)
– Fat intake (% of calories)
• Low fat:
• Low cho:
33% to 33%
33% to 41% (p<.001)
• Drop-out rate at 6 months
– Low fat:
– Low cho:
47%
33% (ns)