Diet Advice for Obesity Part-II-Intervention

By: Maya Abou Jaoude, MSc. LD Lecturer-Dietetic Internship Coordinator

FNHS-NDU Main Campus

OUTLINE 1-Nutrition Intervention:

Planning and implementation

2-Planning:

A-Energy needs: LCD vs VLCD

B-Macronutrients:

Low CHO

High Protein

C-Exercise and weight loss

3-Implementation:

A-Behavioral approach to weight loss

B-Exchanges and diet planning

1.NUTRITION INTERVENTION Nutrition Intervention comprises two parts: A-Planning -Goal Setting to target the success of intervention -Goal could be loss of 2 Lbs per week or a weight loss of 5-10% within 6 months -Constant re-evaluation of the progress towards the goals to ensure proper course of the intervention B-Implementation -Food and nutrition therapies, nutrition education and counseling. Mahan LK & Escott-Stump S. Krause’s Food, Nutrition and Diet Therapy. 14th Ed. 2016 W.B. Saunders. J Acad Nutr Diet.2016;116:129-147

Planning: A-ENERGY NEEDS

• Energy needs are calculated based on different equations.

• Mostly used and most accurate is Mifflin St Jeor:

10 WT+6.25 HT-5 AGE-161 (for women)

10 WT+6.25 HT-5 AGE+5 (for men)

-Using actual weight to estimate RMR.

-Multiply with Physical Activity factors to estimate total energy needs

J Acad Nutr Diet.2016;116:129-147

Academy of Nutrition and Dietetics recommends:

• Individualized diet

• 1200-1500 Kcal per day for women

• 1500-1800 Kcal per day for men

• Energy Deficit of 500-750 Kcal/day

• One of the restrictive types of diets available.

J Acad Nutr Diet.2016;116:129-147

Many references suggested:

• A typical caloric restriction usually used is of 500 to 1000 Kcal per

day.

-Minimize lean body mass loss

-Enhance long term weight maintenance.

• VLCD are sometimes used (6-10 Kcal/Kg/d-Protein 70-100g/d or

0.8-1.5g/kg)

-Rapid weight loss , suitable for BMI>30Kg/m2

-long term, not very efficient Tsai et al. Obesity2006;14:1283-1293

Rankin. American J Lifestyle Med 2015.Vol 9 no 1

Chaston et al. Int J Obes.2008;32:619-628 Harvie et al.Int J Obes.2011;35:714-727 Tsai et al. Obesity2006;14:1283-1293

More on VLCD

• Another randomized trial done in 2017 by Haywood et al

compared Healthy Eating, Low calorie diets and VLCD

in older adults (65y.o)all coupled with Exercise for a

period of 12 weeks.

• n=36, 40, 41 subjects respectively

• VLCDs could be a potential treatment for Obesity in the

old population. It benefits the nutritional status, especially

in men. Haywood et al.J Gerontol A Bio Sci Med Sci,2017,Vol 00,No 00,1-7

B-Macronutrients: Low Carbohydrate Diets

• 20 g per day of CHO.

• No restriction of Energy or other Nutrients

• Once weight loss is achieved, 50g of CHO is allowed

• No Difference in weight loss was seen as compared to a

low fat LCD at 1 YEAR.(6 months would mark the best

result)

• Greater reduction in LDL was seen with a low fat LCD.

• Greater TG reduction and a larger increase in HDL was

seen with the low CHO LCD. Jensen et al J Am Coll Cardiol 2014;63(25 PA):2985-3023

Low CHO diets

• A randomized trial was done comparing the Zone, Atkins,

Weight watchers and Ornish diet

• Highest weight loss was seen in the Ornish (low fat) and

the Zone (low GI and modified macronutrients) diets

• LDL to HDL ratio was reduced by around 10%

• No effect on BP and Glycemia

• At 1 year, all diets reduced modestly body weight and

selected cardiac factors. ADHERENCE was key. Dansinger et al.JAMA 2005-Vol293,No1

Nordmann et al.Arch Intern Med 2006;166:285-293 Krieger et al.AJCN.2006;83:260-274 Bray et al. Int J Obes.2011;36:448-455 Souza et al.AJCN 2012;95:614-625 Hooper et al.BMJ.2012;345:e7666

B-Macronutrients: Proteins

• Protein will be estimated as 0.8g per Kg actual body

weight.

• The needs could differ with the patient’s condition:

HIGH PROTEIN DIETS • Commonly high protein diets include a minimum of 20% of protein.

• Sometimes completed with consumption of liquid meals or

conventional foods.

• Trials were done on different protein sources (soy or non soy for 12

weeks). No significant differences were seen in both groups. This

suggests the validity of soy proteins like any other animal protein in

HP diets.

Beavers et al.J Nutr Health Aging.2015;19(1):87-95

J Acad Nutr Diet.2016;116:129-147

Noakes et al.AJCN2005;81:1298-306

• Noakes et al, 2005 compared a high protein diet (HP)

with a high CHO (HC) one for 12 weeks , the results

were:

• TAGs levels were mostly affected by HP (0.3 vs 0.1

mmol/l)

• LDL chol, HDL, glucose, insulin, FFA, CRP were affected

in both groups by weight loss.

• Iron status was slightly higher with HP.

• Vit B12 rised with HP(13%), B6 rised in both diets

High protein diets and weight maintenance

• Comparing high CHO with low GI and high protein

diet(30% of total energy).

Results:

• Decrease in REE and TEE mostly with the low fat diet

and least with HP.

• Variations in hormone levels and MS components

occurred during weight maintenance but no favorable

result appeared. Ebbeling et al.JAMA2012-Vol307,No24

• HP(CHO less than 40g), LC (60g/d),healthy eating, LF

comparison.

• Weight change was in favor of the HP diet (a difference

of 4.02Kg) at 6 months, but at 1 year it was a difference

of 1Kg.

• Changes in TG were positive at 6 and 12 months but not

at 17 months

• BP was also affected most by HP Hession et al.Obesity reviews 2008;10:36-50

C-EXERCISE AND WEIGHT LOSS

• A meta-analysis done by Hartmann-Boyce et al in 2014 compared

diet or exercise interventions with combined behavioral weight

management.

• At 12 months, weight loss was greater in the 3d group.

• For weight maintenance a larger energy deficit is needed.

• Current recommendations for PA: 30 min of moderate activity most

days of the week150 min per week

• Higher levels are needed for weight loss maintenance 250 min per

week. Hartmann-Boyce et al. J Acad Nutr Diet.2014;114(10):1557-1568

Donnelly et al.Med Sci Sports Exerc. 2009;41(2):459-471

Further Recommendations

• For weight loss PA should be encouraged with a holistic

weight management program and try to accumulate 150-

420 min of activity per week.

• A moderate to vigorous intensity exercise ranging from

180 to 360 min per week for 8-16 months showed to

decrease around 3% of body weight.

J Acad Nutr Diet.2016;116:129-147

Physical Activity Guidelines Advisory Committee Report Washington DC.US dept of Health and Human Services.2008

Exercise and weight loss

• Vilareal et al in 20111 year RCT

• EX vs Diet vs EX+Diet. N=93 participants

• 90 min ex 3 times a week (all types)

• EX+ Diet group better physical performance (21% vs 12 and 15%)

• Less Decrease in the BMD and Lean body mass

• In many reviews, diet+exercise interventions produced more

weightloss on the long term.However weight regain was seen in both

interventions (D alone or D+E) Wu et al.obesity reviews 2009;10:313-323

De Roon et al.Preventive Medicine Reports 5(2017)118-123

Villareal et al.NEJM 2011;364:1218-1229

Type of Exercise

• A combination of high protein diet and interval training

coupled with some resistance exercise showed to have a

positive impact on weight loss, BMD and other bone

markers as vs normoprotein diets+ or – exercise.

• Intensive exercise (endurance or resistance) combined

with diet produced significantly higher bone mass during

calorie restriction. Thus in a context of weight loss, it is

beneficial for bone health. Courteix et al.PLOS ONE 2015

Nebot et al.Bone 92(2015):116-123

TYPE OF EXERCISE

• Aerobic vs Resistance vs A+R, all coupled with weight

loss;N=141 subjects

• Physical Performance was highest in A+R (21% vs 14%)

• Peak Oxygen consumption was highest in A+R

• Lean mass decreased less in A+R

• BMD decreased less in A+R

• Weight loss was the same in all 3 groups

Villareal et al.NEJM2017;376:1943-1955

3-Implementation: A-BEHAVIOR CHANGE INTERVENTIONS

• Behavior change theories are very powerful within

obesity treatment.

• Using classical conditioning or operant conditioning have

shown to be very efficient.

• CBT approach is also used as it equips the patient with

skills to help develop functional thoughts and behaviors.

J Acad Nutr Diet.2016;116:129-147

• CBT examples include self monitoring, goal setting,

development of problem solving and relapse prevention.

• An example is the look AHEAD study that produced a

4.7 % weight loss vs 2.1% in other groups. Weight loss

maintenance was achieved for a long period of time(8

years) The look AHEAD Study.Obesity 2014;22(1):5-13

Motivational interviewing is also an option.

• Main aim is to be “supportive” and not “persuasive”,

expert driven type of communication.

• Dietitian encourages the patient to be autonomous and

draws out patient’s internal motives and values regarding

behavior change.

• A dietitian must incorporate all of these approaches for a

successful weight loss and weight maintenance

approach.

• Stress management, stimulus control,cognitive

restructuring and contingency management are

necessary. J Acad Nutr Diet.2016;116:129-147

IMPORTANT CONSIDERATIONS

• Diet adherence is of prime importance in the success of

the weight loss plan.

• How different is the patient's usual diet of the new

intervention diet greatly affects the adherence and thus

success of the therapy regardless of the type of diet.

• Diets inducing ketosis could contribute to increase satiety

or decreasing the drive to eat and thus help in adhering

to the diet. Gibson et al. Behav. Sci.2017;7:44

• Self monitoring is very important in a weight loss

program.

• Paper record, web based, mobile devices, mobile apps

or PDAs are all techniques of self monitoring

• Tate et al in 2001 : online self monitoring (OM) group vs

education group. OM Group lost a mean of 4 Kg in 3

months vs 1.7Kg in the Education group. Tate et al.JAMA 2001;285(9):1172-1177

• Breakfast

• Number of meals

• fasting

Final recommendations

Final recommendations

B-EXCHANGES

AND

DIET DESIGN

½ loaf bread = 34g 1 exchange

½ cup lentils= 176g 1 exchange

3 Tbsps powder (22g) 1 cup liquid

1 cup chopped 2 medium

150g

30g 30g cooked

50g raw 5 cuts

1 cube 20g

1 finger or 1 layer 30g

3 slices 30g

Pistachio 10g or 1 tbsp or 20 pieces

Peanuts 10 g or 10 pieces Almonds 10g or 6 pieces Walnuts 4 halves or 10g Pine seeds 1 tbsp or 12g

CONCLUSION

THANK YOU!