Achievable Dietary Approaches to Prevent Weight Gain and Promote

Health in Midlife Women

Barbara J. Rolls, Ph.D.

Department of Nutritional Sciences The Pennsylvania State University

Protein

Carbohydrate

Fat

fiber

sucrose

fructose

Dietary approaches to obesity have focused on the proportions of macronutrients

The proposed satiety hierarchy

On a reduced-calorie diet the proportions of fat, carbohydrates, and protein had little

impact on weight loss over two years

Sacks, et al., New England Journal of Medicine, 360: 859-873, 2009

Meta Analysis Comparison of Weight Loss Among Diet Programs

• 48 randomized trials; N=7,286 overweight or obese persons • 25 of the studies examined weight loss at one year (n=5,000)

CONCLUSION

• Weight loss differences between individual diets were small • Need to find ways to enhance adherence to a healthy diet

6 Months 12 Months

Low-fat diets Ornish ~ 60 kcal CHO / 10-15% kcal PRO / ≤20% kcal FAT

7.99 kg 7.27 kg

Low-carb diets Atkins, South Beach, Zone ≤40% kcal CHO / 30% kcal PRO / 30-55% kcal FAT

8.73 kg 7.25 kg

Johnston BC, et a. JAMA, 312: 923-933, 2014

Can we leverage eating behaviors to influence satiety, energy intake, and body weight?

Availability

Energy Intake

Portion

size

Variety

Energy density

(kcal/g)

Palatability

Amorphous Entrées Unit Foods

Beverages Snacks

Naturalistic settings Fisher et al., 2003 Dilberti et al., 2004 Wansink et al., 2001 Wansink et al., 2005

Engell et al., 1995 Rolls et al., 2000 Fisher et al., 2003 Rolls et al., 2004 Kral et al., 2004 Fisher, 2007

Rolls et al., 2004 Raynor et al., 2007 Wansink et al., 2001 Wansink et al., 2005

Flood et al., 2006 Rolls, Roe, Meengs, 2007

Rolls et al., 2004 Geier, et al., 2006 Fisher et al., 2007

Fruits and Vegetables Spill et al., 2010, 2011 Rolls et al., 2010 Mathias et al., 2011 Kral et al., 2010 Rolls et al., 2010

Big portions =

Big intake

Does our biology help us to resist the effect of portion size on intake?

100% portions 150% portions

Breakfast

Lunch

Dinner

+ Afternoon snack

+ Evening snack

The effect of portion size on intake was sustained for 11 days

05000

10000150002000025000300003500040000

Cumulative energy intake (kcal)

Women 100% portionsWomen 150% portionsMen 100% portionsMen 150% portions

4606 ± 771 kcal

5027 ± 735 kcal

Study dayMon

TueWed Thu Fri Sat

SunMon

TueWed Thu

Rolls, Roe, & Meengs, Obesity, 15: 1535-1543, 2007

Prevalence of weight control strategies among obese NHANES participants trying to lose weight

(n = 2523)

Nicklas et al., Am J Prev Med, 42: 481-485, 2012

2010 guidelines emphasize portion control, but it is not clear how to do this or what the impact will be

800 calories 400 calories 400 calories

Higher ED Higher ED Lower ED

“Eat Less” could mean a plate half empty

You can have a full plate when cutting calories

The key is to lower the energy density (ED)

From the Ultimate Volumetrics Diet, Morrow, 2012

700 grams 320 grams

Each tray contains: 475 kcal

10% protein 60% carbohydrate

30% fat

Dietary patterns can be very different even when calories and macronutrient

proportions are similar ED = 0.7 ED = 1.5

Macronutrients can influence intake through their effects on energy density (ED)

• Fat reduction can have a large effect on ED • Water incorporation has the biggest impact on ED

– Water lowers ED even of high-fat foods – Water can come from vegetables and fruits

Fat Carbohydrates & Protein Water in food

9 kcal/g 4 kcal/g 0 kcal/g

Filling up first How to have an extra course and eat less

First course Main course

Eat soup

• Consume water in food, not just as a beverage

• Enhance soup with veggies & beans (for fiber) and lean protein

• Clinical trials show soup aides weight loss

Rolls, et al., American Journal of Clinical Nutrition, 70:448-455, 1999 Rolls BJ, Roe LS, Beach AM, Kris-Etherton PM. Obesity Research, 13, 1052-1060, 2005

- 107 kcal No change + 145 kcal

100 kcal 200 kcal 400 kcal

Eating a large low-energy-dense salad reduced energy intake at lunch compared

with no salad

Keep total salad calories low

Rolls, Roe, & Meengs, J Am Dietetic Assn, 104: 1570-1576, 2004

Whole fruit increases satiety more than pureed fruit or juice

Whole apple Applesauce

Apple juice with fiber

Apple juice

Flood-Obbagy & Rolls, Appetite, 52: 416-422, 2009

How to fill your plate during the main course

• Reduce the energy density of meals by substituting water-rich ingredients for those higher in energy density • Puréed or chopped vegetables and fruit can be

incorporated into many recipes

For 325 calories:

What is the effect of varying energy density when macronutrient proportions

are kept constant?

Bell et al., Am J Clinical Nutrition, 67: 412-420, 1998

Palatability was similar across conditions

Adults ate a consistent weight of food and fewer calories when ED was reduced

0

500

1000

1500

2000

2500

3000

Low Energy DensityMed. Energy DensityHigh Energy Density

B BL LD DS S

Day 1 Day 2Meals

Food

inta

ke (g

)

0

500

1000

1500

2000

2500

3000

3500

4000

Low Energy DensityMed. Energy DensityHigh Energy Density

B BL LD DS S

Day 1 Day 2

a

ab a

aa

a

aa

a

aa

aa

bb

b

b

cb

b

Meals

Ener

gy in

take

(kca

l)

Food intake (g) Energy intake (kcal)

Bell et al, Am J Clinical Nutrition 67: 412-420, 1998

Combining reductions in energy density and portion size has

substantial effects on calorie intake

Smaller portion Bigger portion Smaller portion Bigger portion

Lower density Lower density Higher density Higher density

Learn to modify your favorite foods

Rolls, Roe & Meengs, Am J Clinical Nutrition, 83: 11-17, 2006

Two strategies for eating 1600 kcal

during a day

Food ED = 2.5 590 grams

2260 grams Food ED = 0.7

Can we use what we know about energy density to design diets that facilitate weight management?

Rolls, The Ultimate Volumetrics Diet, Morrow, 2012

How do two strategies to reduce the energy density of the diet affect weight loss?

• Reduce fat intake and restrict portions

RF + FV Group:

• Increase intake of high-water/high-fiber foods – Vegetables, fruits, soups

• Emphasize portion control only for energy-dense foods – High-fat foods and foods with low moisture content

Neither group counted calories or fat grams

RF Group:

3 6 9 12

-12

-10

-8

-6

-4

-2

0

2

RF+FV group (n = 35)

Phase 1 Phase 2

-24

-20

-16

-12

-8

-4

0

4

RF group (n = 36)

Duration (months)

Cha

nge

in b

ody

wei

ght (

kg) C

hange in body weight (lb)

Both groups were successful, but the RF + FV group lost more weight

p < 0.04 p < 0.002

Ello-Martin et al., Am J Clinical Nutrition, 85: 1465-1477, 2007

Weight loss was related to change in food ED over 6 months in the PREMIER (DASH) trial

-200

-100

0

100

200

300

- 91

+ 73

+ 297

Food

wei

ght (

g/d)

-600

-500

-400

-300

-200

-100

0+ 11

- 278

- 511

Ener

gy in

take

(kca

l/d)

Small decrease in ED or increase in ED (n = 219) Modest decrease in ED (n = 220) Large decrease in ED (n = 219)

-15

-10

-5

0

- 5

- 9

- 13

Bod

y w

eigh

t (lb

)

Change in Food Weight

Change in Energy Intake

Change in Body Weight

Ledikwe et al., Am J Clinical Nutrition, 85: 1212-1221, 2007

Strategies that focus on energy density can also help to prevent weight regain after weight loss

Lowe et al., Obesity, 22: 94-100, 2014

0

1

2

3

4

5

6

7

Control

Meal replacement

Energy density

Energy density +meal replacement

3 12 24 36

Weightchange

(kg)

Follow up month

An emphasis on energy density fits with guidance from most major health organizations

http://www.cdc.gov/nccdphp/dnpa/nutrition/pdf/Energy_Density.pdf

Perez-Escamilla, et al., J Acad Nutr & Dietetics, 112: 671-684, 2012

http://www.obesity.org/publications/energy-density-of-foods-influences-satiety-a-total-caloric-intake.htm

607 calories

293 calories

• They emphasize portion control for energy-dense foods

• They suggest eating a greater variety of low-ED nutrient-rich food

Strategies are needed that will facilitate substitution of lower-ED foods for high-ED foods

These must be feasible for food providers and acceptable and affordable for consumers

HarperTorch 2003

HarperCollins, 2007 Morrow, 2012