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Nutrition Interventions in the Treatment of Obesity

Nutrition Interventions in the Treatment of Obesity. Dana White, MS, RD, LDN October 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.

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Nutrition Interventions in the Treatment of Obesity

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  1. Nutrition Interventions in the Treatment of Obesity Dana White, MS, RD, LDN October 25, 2013

  2. Outline • Problem of Obesity • Energy Balance Equation • Nutrition Interventions • Energy Density • Meal Frequency • Role of Protein • Meal Replacement Products • Planning • Take home messages

  3. Problem of Obesity http://www.cdc.gov/obesity/data/adult.html • 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.

  4. Energy Balance Equation Graphic: Eat Well, Live Well. A Healthy Way of Life Nutrition Manual. LifeTime Fitness, 2011.

  5. Segal KR et al. Am J ClinNutr. 1984;40:995-1000

  6. NUTRITION Intervention 1EAt more, Weigh Less

  7. Trying to Reduce your Calories?

  8. 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

  9. Weight of Food Ledikwe JH, et al. Am J ClinNutr 2007; 85:1212-21. 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’sa lot of calories. If the grams come from low energy dense foods, you’ll eat less kcal = weight loss…?

  10. Energy Density Food Examples 160 calories / 34g = 4.7

  11. Energy Density • Influenced by the consumption of fruit, vegetables, fiber and fat. • Fruits and vegetables = ↑ water content. Water adds weight but not kcal to foods. • Fiber- provides volume, takes longer to digest helping you to feel full on fewer kcal • Lower Fat choices - 9 kcal/g versus 4 kcal/g for CHO and Pro.

  12. Energy Density Food Examples ≡

  13. Energy Density Food Examples ≡

  14. Energy Density Food Examples

  15. The DASH Diet (Dietary Approaches to Stop Hypertension) http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf Sacks FM et al. ClinCard 1999;22(SIII), III-6-III-10. Azadbakht L et al. Diabetes Care 2011;34)(1):55-57. Miller ER et al. Hypertension, 2002;40:612-618. • 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)

  16. DASH Diet Rich in magnesium, potassium, and calcium Plenty Fruits Vegetables Low-Fat Dairy Whole Grain Products Lean Meat, Fish, Poultry Nuts 8-12/day 3/day 6-8/day 3-6oz/day 3-6/week Limit(<5/week) Red Meats Sweets Sugar-Containing Beverages

  17. Weight Loss Outcomes with DASH Weight (kg) p<0.001 Ledikwe JH, et al. Am J ClinNutr 2007; 85:1212-21. • 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)

  18. PREMIER Trial Results • Greatest reduction in energy intake seen), BUT, total weight of food increased (+>250g). p<0.001 Food (g) • Accompanied by the largest ↑in fruits, vegetables and dairy and largest ↓ in meat, fats and oils and sweets (+250g). Ledikwe JH, et al. Am J ClinNutr 2007; 85:1212-21.

  19. PREMIER TRIAL RESULTS Mean kcal intake ↓ by ~500 kcal/d AND mean weight of food ↑ by ~300g/d (2/3 pound) from baseline. Ledikwe JH, et al. Am J ClinNutr 2007; 85:1212-21.

  20. 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 ClinNutr 2007;85:1465-77.

  21. How do we help patients do this? Vegetables Protein Starches • 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

  22. 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

  23. Pasta Makeover Whole grain pasta with marinara sauce 1 cup = 415 kcals ED: 2.08 Whole grain pasta w/ vegetables in a marinara sauce 1 cup = 222 kcal ED: 1.0 1 cup = 140 cals ED: 0.86 Fettucini Alfredo

  24. Which would fill you up more? =

  25. NUTRITION Intervention 2Meal frequency

  26. 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

  27. Meal Frequency 1. Drummond et al. J ObesRelatMetabDisord. 1998;22:105-112. 2. Arciero et al. Obesity2013;21:1357-1366 3. Bachman, JL and Raynor HA. Obsesity 2012;20:985-992. 4. MunstersMJM and Saris WHM. Plos One 2012;7(6):e38632. • 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

  28. NUTRITION Intervention 3Protein power

  29. How Much Protein? Evans et al. Nutr & Metab. 2012, 9:55 Wycherley et al. Am J Clin Nutr. 2012;96(6):1281-98 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. CollNutr. 23:5;373-385

  30. Role of Protein in Weight Loss • Halton T, Hu F. Jour Amer. CollNutr. 23:5;373-385 • 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 satiety

  31. Higher Protein, Low Fat Diets Wycherley et al. Am J Clin Nutr. 2012;96(6):1281-98 Arciero, et al. Obesity. 2013;21(7):1357-66 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

  32. 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

  33. Helping Patients Incorporate Protein • Have a protein with each meal andsnack • 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

  34. NUTRITION Intervention 4Meal Replacement Products

  35. 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

  36. MRPs and Weight Loss Ashley JM, et al. Arch Intern Med 2001; 161: 1599-1604. Lowe, et al. Obesity 2013; DOI: 10.1002/oby.20582 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.

  37. 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)

  38. 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)

  39. 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.

  40. Nutrition Intervention 5Be one step ahead

  41. 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?

  42. Take HOME MESSAGES

  43. 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

  44. Other Factors … Self-monitoring – calorie/exercise tracking apps Sleep – at least 6-8 hours/night Exercise Accountability

  45. Thank you!

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