How to Assess a Patient’s Diet and using LCD and VLCD for

Weight loss and Weight Management

David Heber, MD,PhD, FACP, FACN

Professor of Medicine and

Director, UCLA Center for Human Nutrition

Disclosures

Dr. David Heber has received book royalties and travel reimbursement from Herbalife International.

What Influences Food Choices• TASTE

Sugar, Fat, and Salt

• COST

Lowest Cost Foods Have Lowest Nutrient Density (Drewnowski)

• CONVENIENCE

Quick Serve Restaurants (Fast Foods)

Corporate Goal – a store within 7 minutes of every American

Our Genes Evolved on Plant-Based Diets

Subsistence AgricultureFood ScarcityAdapted to Malnutrition

Globalization of theWestern Diet Pattern

Industrial AgricultureGovernment SubsidiesIncreased AvailabilityPoor Food QualityObesity and Chronic Diseases

What are the Differences ?

vs.

1. 10% Fat 2. omega-6/omega-3 ratio 3:13. Good Fructose with Antioxidants

Fiber, Water, Few Calories4. Plant Proteins with lower calories

can be prepared with little fat5. Rich in Vitamins, Minerals, and Micronutrients

1. 35 to 50% Fat Calories2. Omega 6/omega 3 ratio 10-30:13. Bad Fructose as hidden sugars with High Calories, Low Fiber,

Low Antioxidants4. Animal Protein with Saturated Fat

and Increased Calories5. Poor in Vitamins, Minerals and Micronutrients

Sodas

Cakes, Pastries, Donuts

Burgers/Cheeseburgers

Pizza

Chips/Popcorn

Rice

Rolls, buns, muffins, bagels

Cheese

Beer

French Fries

7%

10%

13.8 %

16.8 %

19.7 %

22.4 %

25 %

27.6 %

30.2 %

32.4 %

Calorie Contribution of Foods in the American Diet

Food Percent of Calories (cumulative)

Strategies for Changing the Western Diet and Lifestyle

• Increase Physical Activity• Change the Nutritional Environment• Eat less Fat, Saturated Fat and Cholesterol• Eat more Fiber• Eat a diet with plenty of Grains, Vegetables

and Fruit• Use alcohol in moderation• Use sugar and salt in moderation• Reduce Stressors

Jennifer Anniston used this diet to lose 18 lbs in just 1 month. She recommends this exact diet to anyone looking to lose body fat. Stars such as Kim Kardashian, Britney Spears, and Jennifer Lopez are known for their rapid weight loss.

Women's Health magazine uncovers the secret method they used to lose up to 18 pounds of fat in 1 month.

Weight Loss Goalsof Overweight Women

Imagined Goal % of Initial Weight % Reaching GoalDream Weight - 38% 0%Happy Weight - 31% 9%Acceptable Weight - 25% 24%Disappointed Weight - 17% 20%Below Disappointed ---- 47%

291 lbs 185 lbs

A Simple BMI Chart

5'4"

Weight (lbs)Weight (lbs)

5'2"

5'0"

5'10"

5'8"

5'6"

6'0"

6'2"

120 130 150 160 170 180 190 200 210 220 230 240 250140 260 270 280 290 300

6'4"

Utility and Limitations of BMI Permits population-based studies of trends in

obesity and is used for clinical guidelines. Does not correlate well with fat mass in both over-

muscled (athletic) and under-muscled (sarcopenic) patients.

Does not reveal differences in fat distribution (visceral vs. subcutaneous).

Does not measure fat directly but correlates with body fat over thousands of average patients.

At any given BMI, women have more fat than men.

Lean Body Mass is 70% Water and Conducts Electromagnetic Energy,

but Fat Does Not

Magnetic Resonance Imaging (MRI)

EVEN IF YOU ARE THIN YOU CAN BE FAT

MRI reveals fat around the Heart, Liver and Intestine inIndividuals with Normal Waist Circumference

Of the women scanned by Bell and his colleagues, as many as 45 percent of those with normal BMI scores (20 to 25) actually had excessive levels of internal fat. Among men, the percentage was nearly 60 percent.

Many of Us Lose Muscle with Age: Inadequate Many of Us Lose Muscle with Age: Inadequate Protein & ExerciseProtein & Exercise

Same Weight, Different Muscle Mass Same Weight, Different Muscle Mass

21 year old Female

(BMI = 24.3 kg/m2)

73 year old Female

(BMI = 24.5 kg/m2)

Adapted from: Gallagher et al. Am J Clin Nutr 2000;72:694.

Body Mass Index (kg/m2)

0

10

20

30

40

50

60

70

0 10 20 30 40 50 60

Bod

y Fa

t (%

)

Women

Men

Intra-Abdominal fat

Macrophage and the Innate Immune System Pro-Inflammatory Cells Ingress Mediates the Inflammatory State of Adipose Tissue

The Difference Between Muscle and Fat Cells

Muscle Burns 30 kcal/kg

Fat Burns 6 kcal/kg

The Best Correlate of Resting Energy Expenditure is the Lean Body MassSo When Muscle is Lost in Sarcopenic Obesity the Resting Metabolic Rate Is Reduced and Weight Gain occurs without a large increase in food intake.

Could Protein Supplementation

During Weight Loss Improve Outcome and Maintain

Lean Body Mass ?

Dynamics of protein turnover

Protein intake100 g

gut Secreted GI Proteins 70 g

Fecal loss10 g

Body ProteinTurnover250 g

Body protein stores 10,000 g

Muscle 50 g

Absorbed160 g

Free amino acid“pool” 100 g

Liver 25 g

Blood cells28 g

Skin 2 g

Urinary loss 80 g

One Index of Protein Balance is Nitrogen Balance

Assess balance at several different protein intakes above and below the estimated requirement level to end up with the RDA.

Nbalance = Nintake - Noutput

Determining the RDA

-40-30-20

-100

1020

3040

0.2 0.4 0.6 0.8 1

Egg Protein Intake (g/kg/day)

Nitr

ogen

Bal

ance

(m

g N

/kg/

day)

Young et al. 1973

Protein requirements in endurance athletes:

Meredith et al. 1989

Weightlifters in Balance at 2.5 g/kd/day

Tarnopolsky et al. 1992

Dietary Reference Intakes (DRIDietary Reference Intakes (DRI))Acceptable Range of Macronutrient Intake for ProteinAcceptable Range of Macronutrient Intake for Protein

Risk ofInadequacy

Risk of AdverseAffects

RDARDA ULUL

acceptableintake

Protein: 0.8 g/kg 2.5 g/kgProtein: 0.8 g/kg 2.5 g/kg 10% of kcal 35% of kcal10% of kcal 35% of kcal

Habitual protein intakes in the U.S.Habitual protein intakes in the U.S.

Adapted from Fulgoni, VL. Am J Clin Nutr 2008;87:1554S-1557SAdapted from Fulgoni, VL. Am J Clin Nutr 2008;87:1554S-1557S

Mean ± SDMean ± SD

Adapted from Fulgoni, VL. Am J Clin Nutr Adapted from Fulgoni, VL. Am J Clin Nutr 2008;87:1554S-1557S2008;87:1554S-1557S

Lower acceptable macronutrient distribution

Upper acceptable macronutrient distribution

Error bars indicate 95th percentile

Habitual protein intakes in the U.S.Habitual protein intakes in the U.S.

Daily patterns of protein intake in younger and older Daily patterns of protein intake in younger and older adultsadults

BkftBkft LunchLunch DinnerDinner SnackSnack TotalTotal

Protein intake (g/d)Protein intake (g/d)

YoungerYounger 11.111.1 25.425.4 43.043.0 8.88.8 88.388.3

OlderOlder 13.313.3 20.220.2 35.835.8 7.27.2 76.576.5

Protein intake (% of energy)Protein intake (% of energy)

YoungerYounger 11.811.8 16.116.1 18.818.8 7.57.5 14.814.8

OlderOlder 13.113.1 16.816.8 18.718.7 8.18.1 15.315.3

Energy intake (kcal/d)Energy intake (kcal/d)

YoungerYounger 377377 631631 914914 469469 23912391

OlderOlder 405405 479479 766766 355355 20052005

Adapted from Howarth, NC. Int J Obes 2007;31:675-684

Meal Patterns:Meal Patterns:

Breakfast~10 g

protein

Lunch~20 g

protein

Dinner~60 g

protein

Unbalanced Protein Distribution

response range for protein synthesis (skeletal muscle)

Muscle Protein Balance

Bala

nce

Time

Meal Meal MealPhillips. Nutrition ‘04

Protein accretion

Protein loss

Protein synthesisProtein synthesis

Protein breakdownProtein breakdown

Breakfast

protein

Lunch

protein

Dinner

protein

Breakfast~10 g

protein

Lunch~20 g

protein

Dinner~60 g

protein~30 g ~30 g ~30 g

Balanced Protein Distribution Unbalanced Protein Distribution

{Maximum protein synthesis}

Meal Patterns:Meal Patterns:

Muscle Protein Balance

Bala

nce

Time

breakfast lunch dinner

Protein accretion

Protein loss

Protein synthesisProtein synthesis

Protein breakdownProtein breakdown

Composition of breakfast mealsComposition of breakfast meals

Meal size: 400 kcalMeal size: 400 kcal(gm) (gm) proteinprotein leucineleucine carbohydrcarbohydr fatfat

PROPRO 32 32 2.70 2.70 39 39 1313

CHOCHO 12 12 0.66 0.66 59 59 1212

Layman J. Nutr. 133:411, 2003

Maintenance of Lean body mass with higher protein intake

Time course changes for the ratio of loss of body fat compared with loss of lean body mass (fat/lean) during weight loss for adult women consuming diets with a carbohydrate (CHO)/protein ratio of 3.5 (CHO Group) or 1.4 (Protein Group).

Layman DK et al. J. Nutr. 133:411-417, 2003

fat as % of loss:CHO = 68%PRO = 80%

BarsFruit

vegetableslow fat curd

joghurt

Liquid 2 Liter / day

Breakfast Snack Lunch Snack Sensible meal

MR MR

Beipiel für eine vernünftige Mahlzeit

BarsFruit

vegetableslow fat curd

joghurt

Partial Meal Replacement Plan

Four-year weight losses in the Look AHEAD Study: Factors associated with long-term success in

subjects with T2D

Wadden et al. Obesity (Silver Spring). 2011;19(10):1987-1998

DSE: Diabetes Support and Education groupILI: Intensive Lifestyle Intervention group Dietary intervention included the intensive use of MR and structured meal plans: The first 4 months 2 MR and 2 SR per day, the following months 5-12, 1 MR and 1 SR per day

Wadden TA et al. Obesity Spring) 2009;17(4):713-22

One-year weight losses in the Look AHEAD Study: Factors associated with success

Percentage reduction in initial weight at 1 year based on quartile of meal replacement products used. The numbers within each bar shows the mean number of products used in that quartile.

Fruit & Vegetable Intake

0

1

2

3

4

5

6

baseline yr 1 yr 2

* * p<0.05

Num

ber

of

serv

ings/

day

Ashley et al Obesity Research 9:S312-S320 (2001)

Control Control + MR

•Provides fat and lean percentages•Predicts Basal Metabolic Rate•Can calculate protein needs based on

Lean Body Mass (0.5 - 1.0 gm/ pound LBM)•Helps establish target weight

Bioelectrical Impedance Analysis

Body Composition Test Summary

Sex: Female Height: 64 inchesAge: 47 Weight: 165

TEST RESULTS

Percent Body Fat: 38 %Fat Body Weight: 62.7 lbsLean Body Weight: 102.3 lbsBasal Metabolic Rate 1412 kcal/day

Building the Diet• Body composition analysis provides Resting

Metabolic Rate (RMR); good first estimate for calories needed for weight loss

• Body composition determines lean body mass; up to 1 gram of dietary protein/pound of LBM

• For most overweight women, 1200 calorie diet with 75 gm protein per day good starting point; 1500 calories and 100 gm protein for men

• Build diet around protein, fruits, vegetables; add whole grains as calories allow

Selecting a Meal Replacement• Calories: 300 or fewer• Protein: 15 grams or more• Fat: 5 grams or fewer• Vitamin and Mineral fortified drink or bar• Fiber: at least 5 grams• Vary flavors, textures (drinks, bars, meals• Patients design and tailor their own shake

based on protein needs and tastes

Building the Diet: Protein First

• If possible, determine lean body mass by bioelectrical impedance; diet should supply up to 1 gram of lean protein per pound of lean body mass

• If LBM reading not available, most women will need 75-100 grams of protein per day

• Aim for two meal replacements per day, providing approximately 25 grams protein each to start

Customizing Protein Intake

• Lean Body Mass obtained from body composition analysis

• Select protein level in closest increment of 25 grams

• Use flavored soy or soy/whey protein powder as basis for shake

• Mix shake with milk or soy milk

• Customize with additional plain protein powder for increased protein/satiety

Example

• Flavored soy protein powder + nonfat milk = approximately 25 grams protein per shake (15 + 10 grams)

• Two shakes per day = 50 grams protein

• Protein servings in 25 gram units

• Patient requiring 100 grams per day will need two additional units

Best Protein Sources (3-4 units per day; 135 calories average)

Food Item One Unit Calories Protein (gm)Egg whites 7 whites 115 25Nonfat cottage cheese 1 cup 140 28Soy Protein Powder, flv 1 ounce 140 15 (variesSoy Protein Powder, plain 1 ounce 110 20-25Soy Cereal ½ cup 140 25 (varies)Turkey Breast 3 oz, cooked weight 135 25Chicken Breast 3 oz, cooked weight 140 25Lean Red Meat 3 oz, cooked weight 145-160 25Ocean-Caught Fish 4 oz, cooked weight 130-170 25-31Shrimp, crab, lobster 4 oz, cooked weight 120 22-24Tuna 4 oz, water pack 145 27Scallops 4 oz, cooked weight 135 25Soy Hot Dog 2 links 110 22 (varies)Soy Ground Round 3/4 cup 120 24Soy Burgers 2 patties 160 26Tofu, firm 1/2 cup 180 20 (varies)

Add Vegetable Servings3+ per day, about 55 calories

Food Item Portion Calories Fiber

Cooked Vegetables

Acorn Squash, baked 1 cup 85 6Artichoke 1 medium 60 6Asparagus 1 cup 45 4Beets, cooked 1 cup 75 3Broccoli, cooked 1 cup 45 5Brussels Sprouts 1 cup 60 4Cabbage, cooked 1 cup 35 4Cauliflower, ckd 1 cup 30 3Carrots, cooked 1 cup 70 5Celery, diced 1 cup 20 2Chinese Cabbage, ckd 1 cup 20 3Collard greens, ckd 1 cup 50 5

Add Fruits 3+ per day, about 70 calories

Food Item Portion Calories FiberApricots 3 whole 50 3Avocado ¼ average fruit 80 2

Blackberries 1 cup 75 8Blueberries 1 cup 110 5Cantaloupe 1 cup cubes 55 1

Grapes 1 cup 115 2Honeydew 1 cup cubes 60 1Kiwi 1 large 55 3Mango ½ large 80 3Nectarine 1 large 70 2

Orange 1 large 85 4Orange Juice ½ cup 50 0Papaya ½ large 75 3Peach 1 large 70 3

Add Grains 1-2 per day,average 100 calories

STARCH/GRAIN

Serving size Calories Fiber (grams) Protein(grams)

CookedBeans

½ cup,cooked

115-140 5-7 7

Brown Rice ½ cup,cooked

110 2 3

Lentils ½ cup,cooked

115 8 9

Whole grainpasta

½ cup,cooked

85 2 3

ShreddedWheat, bitesize

1 cup 110 4 5

High FiberBran Cereal

2/3 cup 90-120 15-18 4

Oatmeal 1 cup, cooked 130 4 6Bread, WholeGrain

1 slice 100 3 3-5

Sample Weight Loss Diet Plan - 1200 Calories

BREAKFAST

High Protein Meal Replacement + fruit or

1 cup nonfat yogurt or cottage cheese + fruit or

6 egg white omelet + fruit

LUNCH

Meal Replacement + fruits and vegetables or

3-4 ounces fish, poultry breast or soy protein + salad, vegetables, and fruit

Weight Loss Diet Plan

PM SNACK

1 Fruit serving

DINNER

6 ounces fish, poultry breast or soy protein substitute

1 grain serving

Salad + steamed vegetables

Fruit

Case Study

• Patient is a 42-year-old woman • Married with two teenage children• Works full time• Complains of fatigue, low back pain• Too tired most of the time to exercise• Has sedentary job

Case Study, continued

• Vital signs: afebrile, BP 140/90, P 72• Wt: 170 lb Height: 62” • BMI = 31.5• Waist circumference = 37"• Lab studies:

– Total Cholesterol 210– Triglycerides160– HDL 32– FBS 115 mg/dL

Body Composition Results

• Weight 170 pounds, 62” tall• Fat Mass: 51 pounds; 30.1% body

fat• Lean Body Mass: 119 pounds• Estimated RMR: 1642 cal/day• Target weight: 145 lb for body fat

of 22%

Is this target weight too high?

• Yes, she should weigh no more than130 lb at a height of 5'2" for a BMI of 25

• No, she has increased muscle mass compared to other women her age; if she maintains this lean body mass with concomitant fat loss, she will have a normal BMI at 145 pounds

Dietary History

• Patient relates frequent dieting to keep weight in check

• When dieting, she skips breakfast and eats mostly vegetables and small amounts of protein or pasta for entree

• No vitamin supplements

• When not dieting, she eats pizza, frozen yogurt, and snacks on nuts, cookies, chips

• Drinks 3 regular sodas a day

Typical “Diet” Day

• Breakfast: none, or black coffee and half a grapefruit

• Lunch: large green salad with diet dressing

• Snack: piece of fruit

• Dinner: 2 cups of steamed vegetables, large salad with diet dressing, 1 cup pasta or small chicken breast, fruit for dessert

What “red flags” do you see in her dietary history?

• No multiple vitamin supplements• Low protein intake• High sugar, high fat foods when not dieting• All of the above

Dietary Analysis at a Glance

• Patient takes no multiple vitamin supplements, with an apparently very low-calorie intake on ‘diet days’

• Patient takes no calcium supplements, with no apparent dietary sources

• Protein intake is marginal: 1 ounce of cooked meat, fish, or poultry provides about 7 grams; patient consumes 20+ grams per day but not every day

• Patterns are erratic

Resting Metabolic Rate

• With LBM of 119 lb, patient burns about1642 calories per day

• Since patient is sedentary, calorie needs are not much higher than this for maintenance

• However, she does have more muscle mass than the average woman of her height

Protein Requirements

• With a LBM of 119 lb, patient requires a 60 - 120 grams per day

• Patient currently takes in <30 grams per day on the days she is dieting

• Patient needs to increase protein intake to preserve LBM

• Meal replacements can help provide adequate protein and organize her eating

How much weight will this patient lose on a 1200-caloric diet?

• About 1 lb per week

• Very little without exercise

• 2 lb per week with no difficulty

Recommendations for This Patient

• Needs adequate dietary protein to maintain LBM: recommend 100 grams per day with 2 meal replacements per day

• Patient needs to begin strength training to build muscle and cardiovascular exercise for endurance and to boost calorie expenditure

• Each pound of muscle burns 14 calories; if she can build 10 lb of muscle, she can maintain weight on 140 more calories per day

Additional Recommendations

• Advise patient to use meal replacements and portion-controlled meals to provide proper nutrition with defined calories

• Counsel on avoidance of ‘trigger foods’ – Nuts– Mayonnaise, salad dressings, butter, margarine– Cheese and cheese pizza– Ice cream and frozen yogurt– Red meat and fatty fish– Cakes, pies, pastry, and candy

Partial Meal Replacement Plan

A randomized controlled trialPatients who were transferred to the University Obesity Center for obesity therapy. 1200-1500 kcal/day, 20E% protein, 50-60E% CH, 20-30E% fat for all patients.

Weight loss phase:

3 months:

partial meal replacement plan with 2 meal replacements, two snack replacements and 1 sensible meal/day

versus

conventional diet with 3 meals and 2 snacks

Weight maintenance phase

4 years:

Both diet groups had 1 meal replacement and 1 snack replacement and 2 sensible meals/day

Mean Percent Weight Loss Profiles

month

% w

eig

ht

loss

fro

m b

ase

line

0 10 20 30 40 50

-15

-10

-50

Group AGroup B

Flechtner-Mors, Obes Res 2000

Partial meal replacement planWeight loss and weight maintenance

2 Shakes as mealreplacement

1 Shake as meal replacement

Per

cent

age

redu

ctio

n of

initi

al w

eigh

t Conventional diet

Flechtner-Mors M et al. Obes Res 2000

Months

1 Shake as meal replacement

• Weight loss:

Two daily Meal Replacements were more effective for weight loss than a traditional meal plan using the same prescribed energy content.

• Weight maintenance:

One daily Meal Replacement and Snack Replacement was effective in maintaining weight loss for a period of 4 years.

Partial meal replacement planResults

Why diets with incorporated meal replacements improve weight loss

and weight maintenance

• Easier to plan meals• Reduces barriers to dietary adherence• Helps instill regular eating patterns• May increase accuracy of calorie estimation and

estimation of portion size• Provides a simple guide for healthy nutrition• Positively affects self-monitoring• Facilitates making less deleterious food decisions