nutrition interventions in the treatment of obesity dana white, ms, rd, ldn october 25, 2013
TRANSCRIPT
Nutrition Interventions in the Treatment of Obesity
Dana White, MS, RD, LDNOctober 25, 2013
Outline
Problem of Obesity Energy Balance Equation Nutrition Interventions
Energy Density Meal Frequency Role of Protein Meal Replacement Products Planning
Take home messages
Problem of Obesity Data from National Health and Examination Survey
2009-2010 (1): 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
17-32% PA
60-75% RMR
Thermic Effect of FoodPhysical Activity
Segal KR et al. Am J Clin Nutr. 1984;40:995-1000
NUTRITION INTERVENTION 1EAT MORE, WEIGH LESS
Trying to Reduce your Calories?
Energy Density of Foods
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
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
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Energy Density Food Examples
Energy Density Food Examples
The DASH Diet (Dietary Approaches to Stop Hypertension)
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? CHO: 55%, Fiber: 30g, Pro: 18% ↓ Sodium (<3000mg/d, best BP results with
1500mg/d) 1. http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf2. Sacks FM et al. Clin Card 1999;22(SIII), III-6-III-10.3. Azadbakht L et al. Diabetes Care 2011;34)(1):55-57.4. Miller ER et al. Hypertension, 2002;40:612-618.
DASH Diet
Plenty
Fruits
Vegetables
Low-Fat Dairy
Whole Grain Products
Lean Meat, Fish, Poultry
Nuts
Limit (<5/week)
Red Meats
Sweets
Sugar-Containing Beverages
Rich in magnesium, potassium, and calcium
8-12/day
3/day
6-8/day
3-6oz/day
3-6/week
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)
Ledikwe JH, et al. Am J Clin Nutr 2007; 85:1212-21.
-7
-6
-5
-4
-3
-2
-1
0
-1.1
-5.1
-6.1
∆ Body Weight (kg)
Advice GroupWeight Loss
Group
Weight Loss
+DASH
Weig
ht
(kg
)
p<0.001
PREMIER Trial Results
Advice Group Weight Loss Group
Weight Loss + DASH Group
800
900
1000
1100
1200
1300
1021g 1011g
1305g
Total Weight of Food (g)
Food
(g
)
• Accompanied by the
largest ↑in fruits,
vegetables and dairy
and largest ↓ in meat,
fats and oils and sweetsLedikwe JH, et al. Am J Clin Nutr 2007; 85:1212-21.
• Greatest reduction in energy intake seen), BUT, total weight of food increased (+>250g).
(+250g).
p<0.001
PREMIER TRIAL RESULTS
0
400
800
1200
1600998g
1120g 1215g1560 kcal 1476kcal 1396kcal
Food weight (g)
Ledikwe JH, et al. Am J Clin Nutr 2007; 85:1212-21.
Mean kcal intake ↓ by ~500 kcal/d AND mean weight of food ↑ by
~300g/d (2/3 pound) from
baseline.
Energy Density and Weight Loss
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?
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 dishes- pastas, casseroles, soups, stir fry
Add more whole fruits Apples, oranges, grapes, pears,melons, pears, berries, etc Have w/ a protein source Avoid juice
Vegetables
Protein Starches
How do we help patients do this?
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
Pasta Makeover
Fettucini Alfredo
Whole grain pasta with
marinara sauce1 cup = 415 kcals ED: 2.08
1 cup = 222 kcalED: 1.0
Whole grain pasta w/
vegetables in a marinara sauce1 cup = 140
cals ED: 0.86
Which would fill you up more?
=
NUTRITION INTERVENTION 2MEAL FREQUENCY
Meal Frequency 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: 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
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
1. Drummond et al. J Obes Relat Metab Disord. 1998;22:105-112.2. Arciero et al. Obesity 2013;21:1357-13663. Bachman, JL and Raynor HA. Obsesity 2012;20:985-992.4. Munsters MJM and Saris WHM. Plos One 2012;7(6):e38632.
NUTRITION INTERVENTION 3PROTEIN POWER
How Much Protein? 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.
Halton T, Hu F. Jour Amer. Coll Nutr. 23:5;373-385
Wycherley et al. Am J Clin Nutr. 2012;96(6):1281-98
Evans et al. Nutr & Metab. 2012, 9:55
Role of Protein in Weight Loss
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 satietyHalton T, Hu F. Jour Amer. Coll Nutr. 23:5;373-385
Higher Protein, Low Fat Diets
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 SourcesInclude with each meal and snack 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
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
NUTRITION INTERVENTION 4MEAL REPLACEMENT PRODUCTS
What is a MRP? 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.
Examples: Liquid meals, meal bars, calorie controlled packaged meals
MRPs and Weight Loss 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?
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 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)
When could you use a MRP?
Trying to build consistency 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)
Nutrition Facts and MRPs
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
Frozen/pre-packaged meals <300 calories 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.
NUTRITION INTERVENTION 5BE ONE STEP AHEAD
Planning 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 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 …
Self-monitoring – calorie/exercise tracking apps
Sleep – at least 6-8 hours/night Exercise Accountability
Thank you!