Weight ManagementWeight Management

The War on WeightThe War on Weight

25% of men and 25% of men and 40% of women are 40% of women are trying to lose weighttrying to lose weight

Approximately 45 Approximately 45 million Americans million Americans diet each yeardiet each year

Nationwide, 55 Nationwide, 55 million Americans million Americans are actively trying to are actively trying to maintain their maintain their weightweight

The War on WeightThe War on Weight

Consumers spend about $30 billion per Consumers spend about $30 billion per year on weight related items. This includes year on weight related items. This includes diet sodas, diet foods, artificially sweetened diet sodas, diet foods, artificially sweetened products, appetite suppressants, diet products, appetite suppressants, diet books, videos and cassettes, medically books, videos and cassettes, medically supervised and commercial programs, and supervised and commercial programs, and fitness clubs. fitness clubs.

Spending on weight loss programs is Spending on weight loss programs is estimated at $1 to 2 billion per year. estimated at $1 to 2 billion per year.

U.S. food manufacturers are estimated to U.S. food manufacturers are estimated to have spent $7 billion on advertising of have spent $7 billion on advertising of highly processed and packaged foods in highly processed and packaged foods in 1997. 1997.

Why Diets Don’t WorkWhy Diets Don’t Work

Obesity is a chronic diseaseObesity is a chronic disease– Treatment requires long-term Treatment requires long-term

lifestyle changeslifestyle changes Dieters are misdirectedDieters are misdirected

– More concerned about weight loss More concerned about weight loss than healthy lifestylethan healthy lifestyle

– Unrealistic weight expectationsUnrealistic weight expectations

Why Diets Don’t WorkWhy Diets Don’t Work

Body defends itself against weight Body defends itself against weight lossloss

Thyroid hormone concentrations Thyroid hormone concentrations (BMR) drop during weight loss and (BMR) drop during weight loss and make it more difficult to lose weightmake it more difficult to lose weight

Activity of lipoprotein lipase Activity of lipoprotein lipase increases making it more efficient at increases making it more efficient at taking up fat for storagetaking up fat for storage

Weight CyclingWeight Cycling

Typically weight loss is not maintainedTypically weight loss is not maintained Weight lost consists of fat and lean Weight lost consists of fat and lean

tissuetissue Weight gained after weight loss is Weight gained after weight loss is

primarily adipose tissueprimarily adipose tissue Weight gained is usually more than Weight gained is usually more than

weight lostweight lost Associated with upper body fat Associated with upper body fat

depositiondeposition

Weight Gain in AdulthoodWeight Gain in Adulthood

Weight gain is common from ages Weight gain is common from ages 25-4425-44

BMR decreases with ageBMR decreases with age Inactive lifestyleInactive lifestyle Goal: not to gain more than 10-16 Goal: not to gain more than 10-16

pounds more than your weight on pounds more than your weight on reaching the age of 21reaching the age of 21

Changes in Body Changes in Body

CompositionComposition Fluid is usually the first weight Fluid is usually the first weight

lostlost Loss in lean body tissue means Loss in lean body tissue means

lowering the BMRlowering the BMR Weight loss represents a Weight loss represents a

combined loss of lean body tissue combined loss of lean body tissue and fatand fat

Lifestyle Vs. Weight Lifestyle Vs. Weight LossLoss Prevention of obesity is easier than curingPrevention of obesity is easier than curing Balance energy in(take) with energy Balance energy in(take) with energy

out(put)out(put) Focus on improving food habitsFocus on improving food habits Focus on increased physical activitiesFocus on increased physical activities

What It Takes To Lose What It Takes To Lose a Pounda Pound Body fat contains 3500 kcal/lbBody fat contains 3500 kcal/lb Fat storage (body fat plus Fat storage (body fat plus

supporting lean tissues) contains supporting lean tissues) contains 2700 kcal/lb2700 kcal/lb

Must have an energy deficit of Must have an energy deficit of 2700-3500 kcal to lose a pound 2700-3500 kcal to lose a pound per weekper week

Do the MathDo 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

Sound Weight Loss Sound Weight Loss ProgramProgram Rate of lossRate of loss FlexibilityFlexibility IntakeIntake Behavior ModificationBehavior Modification Overall HealthOverall Health

Cutting Back Cutting Back

1200-1500 kcals per day1200-1500 kcals per day Control calorie intake by being aware Control calorie intake by being aware

of kcal and fat content of foodsof kcal and fat content of foods ““Fat Free” does not mean “Calories Fat Free” does not mean “Calories

Free” (or “All You Can Eat”)Free” (or “All You Can Eat”) Read food labelsRead food labels Estimate kcal using the exchange Estimate kcal using the exchange

systemsystem Keep a food diaryKeep a food diary

Regular Physical Regular Physical ActivityActivity Fat use is enhanced with regular Fat use is enhanced with regular

physical activityphysical activity Increases energy expenditureIncreases energy expenditure Duration and regularity are Duration and regularity are

importantimportant Make it a part of a daily routineMake it a part of a daily routine

Behavior ModificationBehavior Modification

Modify problem (eating) Modify problem (eating) behaviorsbehaviors

Chain-breakingChain-breaking Stimulus controlStimulus control Cognitive restructuringCognitive restructuring Contingency managementContingency management Self-monitoringSelf-monitoring

Chain-BreakingChain-Breaking

Breaking the link between two Breaking the link between two behaviorsbehaviors

These links can lead to excessive These links can lead to excessive intakeintake

SnackingSnacking while while watching watching T.VT.V..

Stimulus ControlStimulus Control

Alternating the environment to Alternating the environment to minimize the stimuli for eatingminimize the stimuli for eating

Puts Puts youyou in charge of temptations in charge of temptations

Cognitive Cognitive RestructuringRestructuring Changing your frame of mind Changing your frame of mind

regarding eatingregarding eating Replace eating due to stress with Replace eating due to stress with

“walking”“walking”

Contingency Contingency ManagementManagement Forming a plan of action in Forming a plan of action in

response to a situationresponse to a situation Rehearse in advance appropriate Rehearse in advance appropriate

responses to pressure of eating at responses to pressure of eating at partiesparties

Self-MonitoringSelf-Monitoring

Tracking foods eaten and Tracking foods eaten and conditions affecting eatingconditions affecting eating

Helps you understand your eating Helps you understand your eating habitshabits

Weight MaintenanceWeight Maintenance

Prevent relapsePrevent relapse– Occasional lapse is fine, but take charge Occasional lapse is fine, but take charge

immediatelyimmediately– Continue to practice newly learned behaviorContinue to practice newly learned behavior– Requires “motivation, movement, and Requires “motivation, movement, and

monitoring”monitoring” Have social supportHave social support

– Encouragement from friends/ family/ Encouragement from friends/ family/ professionalsprofessionals

Weight Loss TriadWeight Loss Triad

Control Energy Intake

Perform Regular Physical Activity

Control “Problem” Behaviors

Dieting Can Be Dieting Can Be Hazardous To Your Hazardous To Your HealthHealth

Weight regained consists of a Weight regained consists of a higher percentage of body fat higher percentage of body fat than beforethan before

Less healthy than before dietingLess healthy than before dieting Weight loss diet should Weight loss diet should notnot be be

considered unless you are considered unless you are committed and motivatedcommitted and motivated

Diet Drugs: Diet Drugs: Amphetamine Amphetamine (Phentermine)(Phentermine)

Prolongs the activity of epinephrine Prolongs the activity of epinephrine and norepinephrine in the brainand norepinephrine in the brain

Decreases appetiteDecreases appetite Not recommended for long term use Not recommended for long term use

(dependency)(dependency)

Sibutramine (Meridia)Sibutramine (Meridia)

Enhances norepinephrine and Enhances norepinephrine and serotonin activityserotonin activity

Decreases appetite (eat less)Decreases appetite (eat less) Not recommended for people with Not recommended for people with

HTNHTN

Orlistat (Xenical)Orlistat (Xenical)

Inhibits fat digestionInhibits fat digestion Reduces absorption of fat in the small Reduces absorption of fat in the small

intestineintestine Fat is deposited in the feces, causing Fat is deposited in the feces, causing

side effectsside effects Must control fat intakeMust control fat intake Malabsorption of fat-soluble vitaminsMalabsorption of fat-soluble vitamins Supplements neededSupplements needed

Very Low-Calorie Diets Very Low-Calorie Diets (VLCD)(VLCD) Recommended for people >30% above Recommended for people >30% above

their healthy weighttheir healthy weight 400-800 kcal per day400-800 kcal per day Low carbohydrates and high proteinLow carbohydrates and high protein Causes ketosisCauses ketosis Lose ~3-4 pounds a weekLose ~3-4 pounds a week Requires careful physician monitoringRequires careful physician monitoring Health risks includes cardiac problems and Health risks includes cardiac problems and

gallstonesgallstones

Bariatric SurgeryBariatric Surgery

An increasingly popular option for An increasingly popular option for severely obese people who are severely obese people who are unlikely to lose weight through unlikely to lose weight through conventional meansconventional means

Cost: $20-$35,000Cost: $20-$35,000 Some insurers cover itSome insurers cover it

Candidates for Candidates for Bariatric SurgeryBariatric Surgery BMI of 40 or more—about 100 pounds BMI of 40 or more—about 100 pounds

overweight for men and 80 pounds for overweight for men and 80 pounds for women women

BMI between 35 and 39.9 and a BMI between 35 and 39.9 and a serious obesity-related health problem serious obesity-related health problem such as type 2 diabetes, heart disease, such as type 2 diabetes, heart disease, or severe sleep apneaor severe sleep apnea

Willingness to make associated Willingness to make associated lifestyle changes lifestyle changes

Bariatric SurgeryBariatric Surgery

RestrictiveRestrictive MalabsorptiveMalabsorptive Combination Combination

restrictive/malabsorptiverestrictive/malabsorptive

Restrictive Surgery: Restrictive Surgery: Adjustable Gastric Adjustable Gastric BandBand

Diet After SurgeryDiet After Surgery

After restrictive surgeries, After restrictive surgeries, patients can only eat ½ cup to 1 patients can only eat ½ cup to 1 cup of food at a timecup of food at a time

Foods often must be soft and Foods often must be soft and chewed thoroughlychewed thoroughly

Patients who eat too fast or the Patients who eat too fast or the wrong kinds of food may have wrong kinds of food may have vomitingvomiting

Restrictive/Restrictive/Malabsorptive: Roux en Malabsorptive: Roux en YY

Diet Books: Big BusinessDiet Books: Big Business

The original Dr. Atkins Diet Revolution is The original Dr. Atkins Diet Revolution is one of the ten best selling books of all one of the ten best selling books of all timetime

Dr. Atkins New Diet Revolution is still #14 Dr. Atkins New Diet Revolution is still #14 on the NYT paperback advice bestseller on the NYT paperback advice bestseller list (11/04) having been on the list for list (11/04) having been on the list for yearsyears

The South Beach Diet has been on the The South Beach Diet has been on the NYT hardcover advice bestseller list for 81 NYT hardcover advice bestseller list for 81 weeks, and is currently #4. weeks, and is currently #4.

Low Carbohydrate Low Carbohydrate Diets (Past)Diets (Past) The Scarsdale Medical The Scarsdale Medical

DietDiet The Drinking Man’s The Drinking Man’s

DietDiet Dr. Atkins Diet Dr. Atkins Diet

RevolutionRevolution The Marine Corps DietThe Marine Corps Diet The Last Chance DietThe Last Chance Diet The “Mayo Clinic” DietThe “Mayo Clinic” Diet

Low Carbohydrate Diets Low Carbohydrate Diets (Recent)(Recent)

Enter the ZoneEnter the Zone Dr. Bob Arnot’s Revolutionary Weight Dr. Bob Arnot’s Revolutionary Weight

Control ProgramControl Program Protein PowerProtein Power Sugar BustersSugar Busters Dr. Atkins New Diet RevolutionDr. Atkins New Diet Revolution Feed Your Kids Well (Atkins for Kids)Feed Your Kids Well (Atkins for Kids) The Fat Flush Plan (Gittleman)The Fat Flush Plan (Gittleman) The South Beach DietThe South Beach Diet

Atkins Diet PremiseAtkins Diet Premise

Stabilizes insulin production by Stabilizes insulin production by limiting carb intake. This forces the limiting carb intake. This forces the body from glucosis into lipolysis, body from glucosis into lipolysis, thus ketones are burned as the thus ketones are burned as the primary energy source.primary energy source.

This results in a metabolic This results in a metabolic advantage of low carbohydrate: advantage of low carbohydrate: dieters can lose weight while eating dieters can lose weight while eating more caloriesmore calories

Atkins DietAtkins Diet

““Induction Phase”: 2 weeks, 20 g Induction Phase”: 2 weeks, 20 g carb/day carb/day

Eliminate fruit, bread, grains, starchy Eliminate fruit, bread, grains, starchy vegetables, dairy products except vegetables, dairy products except cheese, cream, buttercheese, cream, butter

20 g carb: 3 cups salad greens, or 2 20 g carb: 3 cups salad greens, or 2 cups salad plus 2/3 cups cooked cups salad plus 2/3 cups cooked vegetables such as asparagus, summer vegetables such as asparagus, summer squash, green beanssquash, green beans

Atkins DietAtkins Diet

Supplements are recommended Supplements are recommended for everyone: a multivitamin, for everyone: a multivitamin, lecithin, L-glutamine, chromium lecithin, L-glutamine, chromium piccolinatepiccolinate

Can purchase supplements from Can purchase supplements from the Atkins Institutethe Atkins Institute

Recommends exerciseRecommends exercise

Atkins Phase 2: OWLAtkins Phase 2: OWL

““Ongoing weight loss phase” or “Owl.” Ongoing weight loss phase” or “Owl.” Add carbohydrate at a rate of 5 grams Add carbohydrate at a rate of 5 grams

a day until weight loss stopsa day until weight loss stops This is the CCLL: critical carbohydrate This is the CCLL: critical carbohydrate

level for losinglevel for losing May be 45, or 33, or 19 grams/dayMay be 45, or 33, or 19 grams/day Continue at this level until desired Continue at this level until desired

weight is reachedweight is reached

Atkins MaintenanceAtkins Maintenance

Determine CCLM: critical Determine CCLM: critical carbohydrate level for carbohydrate level for maintenance (the level at which maintenance (the level at which weight stabilizes)weight stabilizes)

Most will stabilize at 25 to 90 Most will stabilize at 25 to 90 grams/daygrams/day

If weight gain occurs, return to If weight gain occurs, return to induction dietinduction diet

Atkins- Sample Menu Atkins- Sample Menu Phase 1Phase 1 B: scrambled eggs and ham, butter, B: scrambled eggs and ham, butter,

decaffeinated coffee or teadecaffeinated coffee or tea L: Bacon cheeseburger, no bun, small L: Bacon cheeseburger, no bun, small

tossed salad, selzer watertossed salad, selzer water D: shrimp cocktail with mustard and D: shrimp cocktail with mustard and

mayo, clear consomme, steak, roast, mayo, clear consomme, steak, roast, fish or fowl, tossed salad, diet gelatin fish or fowl, tossed salad, diet gelatin with whipped cream, sf beveragewith whipped cream, sf beverage

Atkins: Sample menu Atkins: Sample menu OWLOWL B: Western omelet, 3 ounces tomato B: Western omelet, 3 ounces tomato

juice, 2 carbo grams of bran juice, 2 carbo grams of bran crispbread, decaf coffee or teacrispbread, decaf coffee or tea

L: Chef’s salad with ham, cheese, L: Chef’s salad with ham, cheese, chicken and egg; zero carbohydrate or chicken and egg; zero carbohydrate or oil and vinegar dressing, iced herbal oil and vinegar dressing, iced herbal teatea

D: Seafood salad, poached salmon, D: Seafood salad, poached salmon, 2/3 cup vegetable from permitted list, 2/3 cup vegetable from permitted list, half cup of strawberries in creamhalf cup of strawberries in cream

South Beach Diet South Beach Diet PremisePremise ““Addiction” to carbs is a psychological need for Addiction” to carbs is a psychological need for

comfort food and is likely a real, physiological comfort food and is likely a real, physiological phenomenonphenomenon

Eating bad carbs leads to cravings for more Eating bad carbs leads to cravings for more which is “ultimately responsible for our obesity which is “ultimately responsible for our obesity epidemic”epidemic”

States that Atkins may limit carbs too severely States that Atkins may limit carbs too severely Stresses glycemic index as the biggest Stresses glycemic index as the biggest

determinant of a food’s potential impact on determinant of a food’s potential impact on body weightbody weight

South Beach Diet: Phase South Beach Diet: Phase 1 (2 weeks)1 (2 weeks) Carbs limited to low-carb vegetables, salads, 1% Carbs limited to low-carb vegetables, salads, 1%

milk, fat-free buttermilk, nonfat yogurt. milk, fat-free buttermilk, nonfat yogurt. Proteins: unlimited lean meats, poultry, fish, low Proteins: unlimited lean meats, poultry, fish, low

fat cheese, tofu fat cheese, tofu Nuts included, but limitedNuts included, but limited ““Good” fats including olive, canola oilsGood” fats including olive, canola oils Sugar-free hard candies, diet gelatin, sugar subsSugar-free hard candies, diet gelatin, sugar subs NO fatty meats, starchy vegetables like corn, NO fatty meats, starchy vegetables like corn,

potatoes, carrots, no fruits, no grains, no alcoholpotatoes, carrots, no fruits, no grains, no alcohol

South Beach: Sample Day South Beach: Sample Day Phase 1Phase 1

B: 6 oz tomato juice, 1/4-1/2 cup liquid egg B: 6 oz tomato juice, 1/4-1/2 cup liquid egg substitute, decaf coffee or tea, non-fat milk, substitute, decaf coffee or tea, non-fat milk, sugar substitutesugar substitute

snack: 1-2 turkey roll upssnack: 1-2 turkey roll ups L: SB chopped salad with tuna, sf gelatinL: SB chopped salad with tuna, sf gelatin snack: celery, 1 wedge Laughing Cow Light snack: celery, 1 wedge Laughing Cow Light

CheeseCheese D: baked chix breast, roasted eggplant and D: baked chix breast, roasted eggplant and

peppers, salad, lo sugar dressingpeppers, salad, lo sugar dressing Dessert: Mocha Ricotta CremeDessert: Mocha Ricotta Creme

South Beach Diet: Phase South Beach Diet: Phase 22 Reintroduces most fruits, whole grains Reintroduces most fruits, whole grains

(sparingly) including popcorn, legumes such as (sparingly) including popcorn, legumes such as pinto beans, starchy vegetables such as peas, pinto beans, starchy vegetables such as peas, carrots and sweet potatoes, flavored nonfat carrots and sweet potatoes, flavored nonfat yogurt, semisweet or bittersweet chocolate, wineyogurt, semisweet or bittersweet chocolate, wine

Still forbidden: white flour and products made Still forbidden: white flour and products made from it including breads, cookies, pasta; from it including breads, cookies, pasta; potatoes, white rice, corn; fruits including potatoes, white rice, corn; fruits including bananas, canned fruit, pineapple, raisins, bananas, canned fruit, pineapple, raisins, watermelonwatermelon

Dieters stay in this phase until goal weight Dieters stay in this phase until goal weight achievedachieved

South Beach: Sample Day South Beach: Sample Day Phase 2Phase 2 B: 1 cup blueberries; 1 scrambled egg w/ salsa; B: 1 cup blueberries; 1 scrambled egg w/ salsa;

oatmeal mixed with 1 cup nonfat milk, oatmeal mixed with 1 cup nonfat milk, sprinkled with cinnamon and walnuts; coffee or sprinkled with cinnamon and walnuts; coffee or teatea

Snack: 4 oz non-fat sugar-free yogurtSnack: 4 oz non-fat sugar-free yogurt L: Tuna salad w/ celery, mayo, tomato, onion in L: Tuna salad w/ celery, mayo, tomato, onion in

whole wheat pitawhole wheat pita Snack: 1 part-skim mozzarella cheese stickSnack: 1 part-skim mozzarella cheese stick D: Pan roasted steak and onions, South Beach D: Pan roasted steak and onions, South Beach

salad, steamed broccoli; chocolate-dipped salad, steamed broccoli; chocolate-dipped strawberriesstrawberries

South Beach Diet: South Beach Diet: Phase 3Phase 3 Maintenance- no foods are Maintenance- no foods are

forbiddenforbidden Continue to limit high carb, Continue to limit high carb,

refined or heavily processed refined or heavily processed foods. foods.

Return to earlier phase if weight Return to earlier phase if weight gain occursgain occurs

South Beach vs Atkins South Beach vs Atkins Phase 1Phase 1

Atkins Atkins Proteins: All meats, Proteins: All meats,

poultry, fish, shellfish, poultry, fish, shellfish, eggs, cheese are eggs, cheese are unlimitedunlimited

Fats: vegetable oils, Fats: vegetable oils, butter, mayonnaise, butter, mayonnaise, heavy cream, baconheavy cream, bacon

Vegetables: 3 cups salad Vegetables: 3 cups salad or 2 cups salad and 2/3 or 2 cups salad and 2/3 cup low carb vegetablescup low carb vegetables

NO: artificial sweeteners, NO: artificial sweeteners, margarine, fruits, grains, margarine, fruits, grains, breads, starchy breads, starchy vegetables, dairy, alcoholvegetables, dairy, alcohol

South BeachSouth Beach Proteins: Lean beef, pork, Proteins: Lean beef, pork,

skinless poultry, low fat skinless poultry, low fat cheese, seafood, eggscheese, seafood, eggs

Fats: Canola and olive oilFats: Canola and olive oil Vegetables: salad greens, Vegetables: salad greens,

beans, tomatoes, cabbage, beans, tomatoes, cabbage, summer squash, broccoli, summer squash, broccoli, all low carb are unlimitedall low carb are unlimited

Dairy: Fat free or 1% milk Dairy: Fat free or 1% milk or yogurtor yogurt

NO: fatty meat, high fat NO: fatty meat, high fat cheese; fruits, grains, cheese; fruits, grains, breads, starchy vegetables, breads, starchy vegetables, butter, margarine, alcoholbutter, margarine, alcohol

High Carbohydrate High Carbohydrate Low Fat DietsLow Fat Diets The Pritikin Weight Loss The Pritikin Weight Loss

BreakthroughBreakthrough Eat More, Weigh Less (Dean Eat More, Weigh Less (Dean

Ornish)Ornish) American Heart Association dietsAmerican Heart Association diets NHLBI TLC dietNHLBI TLC diet

High Carb Low Fat High Carb Low Fat DietsDiets Rationale: diet is high in bulk and Rationale: diet is high in bulk and

fiber, low in calorie density fiber, low in calorie density producing early satiety and producing early satiety and weight lossweight loss

Description: 50-75% carbohydrate Description: 50-75% carbohydrate calories, relatively less meat, fish, calories, relatively less meat, fish, fats and oils, more grains, fats and oils, more grains, cereals, breads, fruits, vegetablescereals, breads, fruits, vegetables

Sample Menu: High Carb Sample Menu: High Carb Low FatLow Fat B: 1 cup blueberries; oatmeal mixed B: 1 cup blueberries; oatmeal mixed

with 1 cup nonfat milk, sprinkled with with 1 cup nonfat milk, sprinkled with cinnamon and walnuts; coffee or teacinnamon and walnuts; coffee or tea

Snack: 4 oz non-fat sugar-free yogurtSnack: 4 oz non-fat sugar-free yogurt L: Vegetarian vegetable soup, fresh L: Vegetarian vegetable soup, fresh

orange, nonfat yogurt orange, nonfat yogurt D: Grilled salmon with yogurt-dill sauce, D: Grilled salmon with yogurt-dill sauce,

bulgur with raisins, steamed broccoli; bulgur with raisins, steamed broccoli; strawberries over angelfood cakestrawberries over angelfood cake

Snack: air popped popcornSnack: air popped popcorn

Research on Research on Macronutrient Mix in Macronutrient Mix in Weight Loss DietsWeight Loss Diets

Low Carb vs Low Fat Low Carb vs Low Fat DietDiet Objective: Compare effects of a low-carb, Objective: Compare effects of a low-carb,

ketogenic diet (Atkins) with those of a low-fat, low ketogenic diet (Atkins) with those of a low-fat, low chol, reduced calorie dietchol, reduced calorie diet

Design: Randomized, controlled Design: Randomized, controlled Subjects: 120 overweight, hyperlipidemic Subjects: 120 overweight, hyperlipidemic

volunteersvolunteers Intervention: Low carb diet (initially <20 g Intervention: Low carb diet (initially <20 g

carb/day) plus nutritional supplementation, carb/day) plus nutritional supplementation, exercise recommendation, and group meetings or exercise recommendation, and group meetings or low-fat diet (<30% energy from fat, <300 mg chol, low-fat diet (<30% energy from fat, <300 mg chol, deficit of 500-1000 kcal/d) plus exercise deficit of 500-1000 kcal/d) plus exercise recommendation and group meetingsrecommendation and group meetings

Yancy, W. S. et. al. Ann Intern Med 2004;140:769-777

Low Carb vs Low Fat Low Carb vs Low Fat DietDiet MeasurementsMeasurements: body weight, body composition, : body weight, body composition,

fasting serum lipid levels and group meetingsfasting serum lipid levels and group meetings ResultsResults: 76% of the low-carb group and 57% of : 76% of the low-carb group and 57% of

the low-fat group completed the study. At 24 the low-fat group completed the study. At 24 weeks weight loss was greater in the low-carb weeks weight loss was greater in the low-carb group (12.9%) than in the low-fat group (6.7%)group (12.9%) than in the low-fat group (6.7%)

Pts in both groups lost more fat mass (-9.4 kg low 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 carb, -4.8 kg low-fat) than fat free mass (-3.3 kg vs -2.4 kg)vs -2.4 kg)

Low carb diet subjects had > decreases in serum Low carb diet subjects had > decreases in serum triglycerides (-74.2 mg.dL vs. -27.9 mg/dL)triglycerides (-74.2 mg.dL vs. -27.9 mg/dL)

Yancy, W. S. et. al. Ann Intern Med 2004;140:769-777

Expected mean body weight over time, by diet group

Low Carb vs. Low FatLow Carb vs. Low Fat

Low carb group had > increases in HDL-C (5.5 Low carb group had > increases in HDL-C (5.5

mg/dL vs. -1.6 mg/dL P<0.001)mg/dL vs. -1.6 mg/dL P<0.001) Changes in LDL-C were not significantChanges in LDL-C were not significant Low carb group had greater participant retention Low carb group had greater participant retention

and greater weight loss over 24 weeksand greater weight loss over 24 weeks Minor adverse effects were more frequent in the Minor adverse effects were more frequent in the

low-carb diet grouplow-carb diet group Limitations: Effects of the low-carb diet and of the Limitations: Effects of the low-carb diet and of the

nutritional supplements could not be separated. nutritional supplements could not be separated. Participants were healthy and were followed for Participants were healthy and were followed for only 24 weeks. only 24 weeks.

Yancy, W. S. et. al. Ann Intern Med 2004;140:769-777

Low carb vs. conventional Low carb vs. conventional 1 year follow up1 year follow up

Objective: Review the 1-year outcomes of Objective: Review the 1-year outcomes of two groups randomized to these dietstwo groups randomized to these diets

132 obese adults, BMI 35 or greater; 83% 132 obese adults, BMI 35 or greater; 83% had diabetes or metabolic syndromehad diabetes or metabolic syndrome

Participants were counseled to either Participants were counseled to either restrict carb intake to < 30g/day or restrict carb intake to < 30g/day or reduce calories by 500 cals/day with reduce calories by 500 cals/day with <30% of cals from fat<30% of cals from fat

Stern, L. et. al. Ann Intern Med 2004;140:778-785

Low carb vs. conventional Low carb vs. conventional 1 year follow up1 year follow up

By 1 year, mean weight change for persons on By 1 year, mean weight change for persons on the low carb diet was -5.1 +/- 8.7 kg compared the low carb diet was -5.1 +/- 8.7 kg compared with -3.1 +/- 8.4 kg for persons on a conventional with -3.1 +/- 8.4 kg for persons on a conventional diet. Differences were not significant (P= 0.20)diet. Differences were not significant (P= 0.20)

Triglycerides decreased more on low carb diet, Triglycerides decreased more on low carb diet, HDL levels decreased less, HbA1c improved moreHDL levels decreased less, HbA1c improved more

Changes in other lipids (LDL, total-C) and insulin Changes in other lipids (LDL, total-C) and insulin sensitivity did not differ between groupssensitivity did not differ between groups

Limitations: 34% drop out rate, suboptimal Limitations: 34% drop out rate, suboptimal dietary adherence; relatively small net weight dietary adherence; relatively small net weight loss in both groupsloss in both groups

Stern, L. et. al. Ann Intern Med 2004;140:778-785

Stern, L. et. al. Ann Intern Med 2004;140:778-785

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)

Low Carb vs. Conventional Low Carb vs. Conventional Diet OutcomesDiet Outcomes

Between 6 months and 1 year, persons in the Between 6 months and 1 year, persons in the low carb group began to regain weight while low carb group began to regain weight while persons on the conventional diet continued to persons on the conventional diet continued to lose weightlose weight

By 6 months, there was no significant By 6 months, there was no significant difference in weight loss between the two difference in weight loss between the two groupsgroups

Intake data suggest that differences in weight Intake data suggest that differences in weight loss, where they exist, are the result of loss, where they exist, are the result of differences in calorie intakes, not a metabolic differences in calorie intakes, not a metabolic advantage of low carbadvantage of low carb

Summary: High Pro Low Summary: High Pro Low Carbohydrate DietsCarbohydrate Diets

Pros: Pros: – High pro low carb diets appear to High pro low carb diets appear to

produce greater short term weight produce greater short term weight lossloss

– In studies, there was a lower dropout In studies, there was a lower dropout rate with high pro low carb dietsrate with high pro low carb diets

– High pro low carb diets produced High pro low carb diets produced favorable lipid changesfavorable lipid changes

Summary: High Pro Low Summary: High Pro Low Carbohydrate DietsCarbohydrate Diets

ConcernsConcerns– long term safety (effects of high pro diet on long term safety (effects of high pro diet on

kidney function, lack of phytochemicals, kidney function, lack of phytochemicals, association of association of ↑ ↑ red meat and red meat and ↑ sfa ↑ sfa intake with intake with ↑ ↑ cancer)cancer)

– questionable rationale (protein stimulates questionable rationale (protein stimulates insulin release)insulin release)

– difficult to follow long termdifficult to follow long term– epidemiological evidence shows vegetarians are epidemiological evidence shows vegetarians are

slimmerslimmer– at risk nutrients: calcium, potassium, vitamin C, at risk nutrients: calcium, potassium, vitamin C,

vitamin Dvitamin D

High Carb Low Fat High Carb Low Fat DietsDiets

ProsPros– Fits most major dietary guidelines Fits most major dietary guidelines

including U.S. Dietary Guidelines, TLC including U.S. Dietary Guidelines, TLC diet, AHA diet; high in fiber and plant diet, AHA diet; high in fiber and plant foods associated with health benefitsfoods associated with health benefits

– Epidemiological evidence associates Epidemiological evidence associates high carb low fat diets with lower rates high carb low fat diets with lower rates of heart disease, cancer, obesityof heart disease, cancer, obesity

– Consistent with pattern reported by Consistent with pattern reported by successful dieters in the National successful dieters in the National Weight Control RegistryWeight Control Registry

Summary: High Carb Low Summary: High Carb Low Fat DietsFat Diets

ConsCons– Produces more gradual weight loss Produces more gradual weight loss

than high protein diets; dieters than high protein diets; dieters become discouragedbecome discouraged

– Very high carb low fat diets Very high carb low fat diets associated with unfavorable lipid associated with unfavorable lipid changes (may need to choose whole changes (may need to choose whole grains, replace some carb with MFA) grains, replace some carb with MFA)

– At risk nutrients: B12, D, E, ZincAt risk nutrients: B12, D, E, Zinc

Weight Loss By Any Weight Loss By Any Method WillMethod Will:: Reduce blood lipid levels including Reduce blood lipid levels including

TC, LDL-C, HDL-C, and TgTC, LDL-C, HDL-C, and Tg Improve glycemic controlImprove glycemic control Reduce blood pressureReduce blood pressure

Especially during active weight Especially during active weight lossloss!!

Low Carb vs Low FatLow Carb vs Low Fat

Weight loss is caused by a deficit Weight loss is caused by a deficit in calories, not a metabolic in calories, not a metabolic advantage of one over the otheradvantage of one over the other

Persons with the greatest calorie Persons with the greatest calorie deficit lost the most weightdeficit lost the most weight

A high protein diet may offer A high protein diet may offer some advantages, perhaps in some advantages, perhaps in simplicity, limiting options, or simplicity, limiting options, or increased satietyincreased satiety

Low Carb vs Low FatLow Carb vs Low Fat

Many VLCD programs offer a high Many VLCD programs offer a high protein, low carb, low fat protein, low carb, low fat approachapproach

People should be offered options People should be offered options in weight managementin weight management

The major issue in diet success is The major issue in diet success is how persons plan to keep the how persons plan to keep the weight offweight off

Diet Quality of Popular Diet Quality of Popular DietsDietsCSFII Data: Healthy Eating IndexCSFII Data: Healthy Eating Index

0

10

20

30

40

50

60

70

80

LOW CHO MOD CHO HIGH CHO

HEI SCORE

Energy Intake of Adults on Energy Intake of Adults on Popular DietsPopular DietsCSFII DATACSFII DATA

1750

1800

1850

1900

1950

2000

2050

2100

2150

2200

LOW CHO MOD CHO HIGH CHO

Energy (kcal)

BMI of Adults on BMI of Adults on Popular DietsPopular DietsCSFII DATACSFII DATA

10

12

14

16

18

20

22

24

26

28

LOW CHO MOD CHO HIGH CHO

MENWOMEN

BMI Vegetarians/Non BMI Vegetarians/Non VegetariansVegetariansCSFII DATACSFII DATA

15

17

19

21

23

25

27

VEG NON-VEG

MenWomen

Energy Intake Energy Intake Vegetarians/ Vegetarians/ Non-VegetariansNon-Vegetarians (CSFII DATA)(CSFII DATA)

0

500

1000

1500

2000

2500

VEG NON-VEG

Energy (kcal)

NHLBI NHLBI Recommendations: Recommendations: Diet Therapy for Weight Diet Therapy for Weight MgmtMgmt Low calorie diets are Low calorie diets are

recommended for weight loss in recommended for weight loss in overweight and obese personsoverweight and obese persons

Reducing fat as a part of LCD is a Reducing fat as a part of LCD is a practical way to reduce calories.practical way to reduce calories.

Plan for a deficit of 500-1000 Plan for a deficit of 500-1000 kcal/day for weight loss of 1-2 kcal/day for weight loss of 1-2 lb/wk lb/wk

NHLBI NHLBI Recommendations: Recommendations: Physical ActivityPhysical Activity Physical activity modestly contributes Physical activity modestly contributes

to weight loss, may decrease to weight loss, may decrease abdominal fat, increases abdominal fat, increases cardiorespiratory fitnesscardiorespiratory fitness

VERY important for wt maintenanceVERY important for wt maintenance Initially 30-45 minutes moderate Initially 30-45 minutes moderate

activity, 3-5 days a weekactivity, 3-5 days a week Long term: 30 minutes + of moderate Long term: 30 minutes + of moderate

intensity activity on most/all daysintensity activity on most/all days

National Weight National Weight Control RegistryControl Registry Self-selected data base of people who Self-selected data base of people who

have lost at least 30 lb and kept it off have lost at least 30 lb and kept it off at least one yearat least one year

Published data on 784 persons, 80% Published data on 784 persons, 80% female, 97% white, 56% with college female, 97% white, 56% with college degrees, mean age 45 yearsdegrees, mean age 45 years

Had average maximum BMI of 35; Had average maximum BMI of 35; most had attempted wt loss numerous most had attempted wt loss numerous timestimes

NWCR: Weight Loss NWCR: Weight Loss MethodsMethods

0

10

20

30

40

50

60

70

80

90

% of Resp

Diet and activityLimit certain foodsFormal prog (incl RD)Limit quantity of foodsCount caloriesLimit fat kcalsLimit fat grams

NWCR: Weight NWCR: Weight Maintenance MethodsMaintenance Methods

0

1020

3040

5060

7080

90100

% of Resp

Limits certain foods

Burns >1000 kcalexercise/wkWeighs self weekly

Limits quantity of food

Limits kcal from fat

Counts kcals

Counts fat grams

Underweight is Also a Underweight is Also a ProblemProblem 15-25% below healthy weight or 15-25% below healthy weight or

BMI of <18.5BMI of <18.5 Associated with increased deaths, Associated with increased deaths,

menstrual dysfunction, pregnancy menstrual dysfunction, pregnancy complications, slow recovery from complications, slow recovery from illness/surgeryillness/surgery

Causes are the same as for Causes are the same as for obesity but in the opposite routeobesity but in the opposite route

Treatment for Treatment for UnderweightUnderweight Intake of energy-dense foods Intake of energy-dense foods

(energy input)(energy input) Encourage meals and snacksEncourage meals and snacks Reduce activity (energy output)Reduce activity (energy output) To gain a pound you need a total To gain a pound you need a total

excess intake of 2700-3500 kcalexcess intake of 2700-3500 kcal