Treatments for Overweight and Obese Clients Dr. David L. Gee FCSN/PE 446 Nutrition, Weight Control &...

Treatments for Overweight and Obese

ClientsDr. David L. Gee

FCSN/PE 446

Nutrition, Weight Control & Exercise

Assessment of Healthy Weight• Body Mass Index (>25)• Risk factors for chronic disease

– High waist circumference– blood pressure (hypertension)– blood lipids (dyslipidemia)

• TC, LDL-C, HDL-C, TG

– Impaired glucose tolerance– family history

• Presence of obesity related disease

The Bottom Line on Weight Control

• Regardless of the characteristics of a weight loss program:

• Negative Energy Balance– Results in weight loss– E(in) is less than E(out)

• Positive Energy Balance– Results in weight gain– E(in) is greater than E(out)

• Energy Balance– Results in weight maintenance– E(in) is equal to E(out)

Treatment Affecting Energy Intake

Treatment Affecting Energy Intake

• Listed from low to high risk

• Healthy diet approach (w/BM)

• Balanced hypocaloric diet (w/BM)– Low Calorie Diet (LCD)

• Drugs

• Very Low Calorie Diets

• Gastric & Intestinal Surgery

Treatment Affecting Energy Expenditure & Losses

Treatment Affecting Energy Expenditure & Losses

• Increase lifestyle activity

• Aerobic exercise (w/BM)

• Strength training (w/BM)

• Drugs (no prescription drugs currently approved)

National Weight Control Registry (University of

Colorado)• ~3000 people • kept >30 lbs off > 1year

– average BMI 35 => 25– Average lost 60 lbs, kept it off for 5 years

• many were overweight as children (2/3), had one or both parents overweight (60%)

• average age 45 yrs• http://www.uchsc.edu/nutrition/WyattJortberg/nwcr.htm

Seven Tips from the National Weight Control Registry

CNN – “Fat Chance”, Nov 2003

• Expect failures but keep trying–Don’t view past failures as signs

you can’t succeed

• Don’t deny yourself–Plan indulgences

• Weigh yourself regularly

Seven Tips from the National Weight Control Registry

CNN – “Fat Chance”, Nov 2003

• Exercise regularly–Walking most popular

• Add a little bit of exercise to your daily activity

• Eat a high CHO/low fat diet• Eat 5 meals a day

Other Tips from the National Weight Control Registry

• No pain, no loss

• Make smaller lifestyle goals

• Exercise & Diet (90%)

• Do what you want, not what you should.

Major Dietary Approaches For Weight Loss

• Healthy Diet/Non-Diet Approach– DASH, Food Guide Pyramid

• Balanced Reduced (Hypocaloric) Diet– Weight Watchers, Jenny Craig, Slim Fast

• Low Carbohydrate Diet– Dr. Atkins

• Restrained Carbohydrate Diet– South Beach Diet, Zone Diet

Treatments for the Overweight Patient (BMI 25-30)

The Non-Diet or Healthy Diet Approach

• Focus on becoming healthy• Success is measured in “units of

health”, not units of weight• Strategies are lifetime, not

temporary• Make a commitment because you

want to, not because you have too.

Dietary Modification for the Overweight Patient

• Focus first on the quality of the diet, second on the quantity.– Food Guide Pyramid– Dietary Guidelines for Americans– DASH diet

• www.nhlbi.nih.gov

– Focus on fruits, vegetables and whole grains

Food Guide Pyramid(the New Food Pyramid has different

pyramids based on energy needs)Energy Intake

1600 kcal 2200 kcal 2800 kcal

Grain 6 9 11

Vegetable 3 4 5

Fruit 2 3 4

Meat (oz) 5 6 7

Fat (g) 53 73 93

Added sugar (tsp)

6 12 18

Portion distortion

Healthy Diet Effects• Healthy diet may or may not result in

weight loss– if weight loss occurs, it will be gradual

• Healthy diet should result in improved health

• Improved health may require more significant weight loss

• A healthy diet is probably the best diet for long-term weight maintenance

Final Exam – 2005Required Readings

• NIH – Clinical Guidelines• WIN Publications (Weight Information

Network)– Statistics– Weight Cycling– Very Low Calorie Diets– Surgical Treatments for Obesity– Pharmacological Treatments for Obesity

• Nutrition Club – Tuesday, 5:30PM, 126 Mich– 2005-06 officer elections– Salmon BBQ

Balanced Hypocaloric Diet• “Low Calorie Diet”

– LCD, not VLCD

• For those who are :–significantly overweight

• BMI >25 w/ health risks

–can not attain good health without significant weight loss

Balanced Hypocaloric Diet• Negative energy balance

– Energy In < Energy Out

• -500 Cal/day energy balance = 1 lb fat/week weight loss

• -EB achieved with COMBINED– dietary caloric restriction– increased exercise – plan a net -EB of -500-1000 Cal/day

Negative EB is Accumulative

• If EB = - 200 Cal/day– decrease food by 100 Cal/day

– increase activity by 100 Cal/day

• In one month EB = - 6000 Cal• at 3500 Cal / lb FAT =>• almost 2 pounds per month• over 20 pound per year weight loss

Composition of Balanced Hypocaloric Diets

• Calories–reduce intake by about 500 Cal/d

–minimum of 1000 Cal/d

• Estimate calories–Calculate energy expenditure

–Food records

Composition of Balanced Hypocaloric Diets

• Low Fat– < 25% of calories

• Moderately high in complex CHO– ~ 60% of calories– Unless pt w/ hypertriglyceridemia

• Reduce CHO 45-50% of calories• Fat 30-35%, mainly unsaturated fats

• Adequate in proteins– > 0.8 gP/kg BW

Forms of Balanced Hypocaloric Diets

• Meal Plans– Dietary exchanges

• Weight Watchers

– Commercial Diet Packages • Jenny Craig• NutriSystems

– Food Supplement/Food Combos • Slim Fast

Metabolic and Weight Loss Effects of Long-term Dietary Intervention in Obese Patients: Four-year ResultsFlechtner-Mors M, et al. Obes Res. 2000;8:399-402.

• Randomized controlled trial– 75 subjects followed for 4 yrs– Control vs Slim-Fast program

• Wt loss at 4 yrs– Control: 3.2% SF: 8.4%

• Fasting blood glucose at 4yrs– Control: 13% lower SF:12% (ns)– Similar findings with fasting insulin

• Systolic and fasting TG lower in SF group

Advantages of Balance Hypocaloric Diets

• Safe• High quality weight loss• More similar as a “Diet for a lifetime”• Large volume of food• No elimination of any food or food

group

Disadvantages of Balanced Hypocaloric Diet

• Another “diet”–going on, going off

• Slow rate of weight loss–think long term

• No “magic”, no gimmick

Final Exam – 2004• Exam Format (see 2003 Study Guide linked

on course web page)– No questions on Ergogenic Aids !– Short answer/essay

• Hypothetical case study– Data on height, weight, risk factors– Do assessment, establish weight goal– Common questions a client might ask

– MC/TF• Information that you might be asked from clients and

health professionals• Research studies presented are to reinforce and confirm

relationships between obesity, weight loss and disease risk.

Dietary Means to a Healthy WeightLow Carbohydrate Diets

• Characteristics– Very low in CHO

• Induction phase: < 20g/d• Maintenance phase: 40-60g/d

– Restricted intakes of fruit, cereals, pasta, bread, potatoes, rice

– Caloric intake not specified

• Examples– Atkins diet

The High Protein/Low Carbohydrate Diets: Rationale:

The high CHO/insulin link

• The Claim:–High CHO diets result in

hyperinsulinemia–Insulin stimulates fat synthesis–therefore high CHO diets result in

gaining fat weight

The High Protein/Low Carbohydrate Diets: Flaws in Rationale

• The Reality:• Hyperinsulinemia is a result, not a cause, of

obesity• Although insulin does stimulate fat synthesis:

– fat synthesis only occurs with +Energy Balance– fat synthesis from CHO is inefficient and with +EB,

body preferentially stores excess dietary fat as body fat

Carbohydrate intake and biomarkers of glycemic control among US adults: NHANES III

AJCN 77:1426-1433 (2003)

• 5730 men, 6125 women– Cross-sectional NHANES III study

• Divided into quintiles based on % CHO calories• No association between CHO intake and:

– HB A1c concentration– Fasting plasma glucose– Fasting serum insulin

• “this supports current recommendations regarding carbohydrate intake in healthy adults.”

• (also note international epidemiological studies)

The High Protein/Low Carbohydrate Diets:Rationale:

Epidemiological Evidence• The Claim:

– Since the 1950’s % FAT has fallen from about 40% to about 34%

– Since the 1960’s the % obese has risen from 25% to about 33%

• Therefore, hi CHO diets have contributed to the increase in weight problems

The High Protein/Low Carbohydrate Diets: Flaws in Epidemiological Evidence

• The Reality:– Studies show that despite an increase in

%CHO in diet, there is increasing obesity.– But, while %CHO increased & %FAT

decreased– TOTAL Calories increased– caloric expenditure decreased – absolute fat intake stayed the same.

The High Protein/Low Carbohydrate Diets: Realities

• Diets low in carbohydrate will deplete glycogen stores – result in significant early water loss– cause premature fatigue during exercise


• High protein diets will result in further weight loss if Ein < Eout

– meat, cheese, egg diets become unappetizing over the long run

– long-term compliance to this restricted diet is likely to be poor

• Diets high in meat … are high in saturated fats and may increase risk of heart disease.– Short term (during active weight loss) may see

improvement in blood lipids


• Low Carbohydrate diets will result in ketosis– most cases degree of ketosis are mild– most cases there is some appetite

suppression– in some cases, there will be ketoacidosis

and electrolyte imbalance - need for physician supervision

The High Protein/Low Carbohydrate Diets: Conclusions

• High protein diets will result in short term weight loss

• Long term effectiveness is very questionable

• Long term effect on health is a concern

A Randomized Trial of a Low-Carbohydrate Diet for Obesity.Foster et al. NEJM 348:2082-90 (2003)

• 66 obese men and women (BMI=34)• Randomly assigned to diets for 1 year• Professional contact minimal to replicate

approach used by most dieters

Weight loss (%BW loss)

• 3 months• Low fat: 2.7% • Low cho: 6.8% (p=0.001)

• 6 months• Low fat: 3.2%• Low cho: 7.0% (p=0.02)

• 12 months• Low fat: 2.5%• Low cho: 4.4% (ns)

Changes in risk factors

• Improved in low CHO diet groups– Serum Triglycerides– HDL-cholesterol

• No difference between low CHO and low Fat diet groups– Blood pressure (ns)– LDL-cholesterol

• NS (but lower in low fat at 3 mo., mean lower at 12 months)

– Insulin sensitivity (ns)

• Drop-out rate:– Low fat: 43%– Low cho: 39%

• Reported adverse reactions higher in Low CHO group– GI problems (diarrhea/constipation)– Bad breath– Fatigue/weakness– headache

Low-Carb DietsSummary of Long-term studies

• What the research shows:– Short-term outcomes

• 6 month studies– Better weight loss– Improved plasma TG and HDL-C– drop-out rate significant in both LC and LF– Adverse effects greater in LC

– Long-term outcomes• 1 year studies

– weight loss no better than low fat group– still improved plasma TG and HDL-C– drop out rate significant in both groups– LC eating more CHO than recommended, low SFA, high MUFA– LF eating more FAT than recommended

Dietary Means to a Healthy WeightThe Carbohydrate ‘Restrained’ Diets

• Characteristics• Lower in CHO than Dietary Guidelines but

higher than Low Carb diets (~40% CHO, 30%FAT, 30%PRO)

• Low glycemic index foods encouraged• Monounsaturated fats encouraged

• Examples– Zone Diet, South Beach Diet

• What the research shows:– Little research available on these diets

Very Low Calorie Diets VLCDs

• Characteristics– 400-800 Cal/d– Generally semi-synthetic beverages– ‘high protein’ (50-100g/d)– Very low fat– Low to moderate CHO– Expensive


• Must be Medically Supervised– Generally safe

• Minor side effects– Fatigue– Constipation or diarrhea– Nausea/dizziness– Cold intolerance

• Possible significant side effects– Gall stones– Electrolyte imbalances


• Patient Criteria– BMI > 30– BMI= 27-30 with medical complications

• Contraindications– Pregnancy– Children– history of

• dysrhythmia of heart• gall stones• renal dysfunction


• Short term outcome– Rapid high quality weight loss

• 30-35 kg in 25 weeks

– Reduction in health risks

• Long term success– No more (or less) successful than other

treatments– Maintenance program (diet, behavior,

exercise) critical for success

Guidelines for Identifying Weight Loss Fraud

• Claims easy, large, fast weight loss

• eat all you want, no exercise

• uses quackery terms

• gets rid of “cellulite”

• relies on undocumented cases


• Claims government approval• gives no or incomplete scientific

references• cures everything• promotes use of unproven aids/gadgets

– equipment– supplements


• Makes claims about “problems associated with combining certain foods in the same meal”

• Describes diet as being opposed by the the established medical community

• Distributed exclusively by mail order, internet, 800 phone, pyramid sales organization

Remaining Fall 2002 Schedule• 12/2

– Hi PRO/low CHO diets– VLCD – see web notes and WIN web reading

– Exercise and weight loss– BM/assessment assignment due

• Turn in: – your BM records– SOAP notes for your client

• 12/4– Pharmacological approaches to weight loss

• 12/6– Surgical methods for weight loss

• 12/13– 8:30-10 – Final Exam

RCT – Atkin’s DietE. Westman, Duke Univ.

presented at 2002 AHA annual meeting

• Funded by R. Atkins Foundation

• 120 overweight subjects– Randomized

• Atkins diet• AHA step 1 diet (US Dietary Guidelines)

– 6 months

RCT – Atkin’s DietWhat does this mean?

• Greater adherence due to novelty?– ADA step 1 diet not much different than typical diet

• Don’t ignore 100’s of studies of CHD dangers of high SFA/chol diets– Based primarily on stable weight

• This is a short term study – Long term weight loss success– Effect of weight maintenance on blood lipids

• Provocative, but…wait and see!

Extra Credit Opportunity• Replaces the 25pt Eating Behaviors Project• Worth 5 extra credit points• Write a 2+ page commentary on the USA

Today article:– Kids need school's help to get healthy

• http://www.usatoday.com/news/health/2003-05-19-fitkids-usat_x.htm

• To get all 5 points, your commentary must be:– Thoughtful (and realistic)– Well organized– Well written– typed

Characteristics of a Healthy Diet

• Low Fat, Low Saturated Fat– reduces CHD, Hpt, cancer risks

– lowers caloric density and may reduce food intake

• reducing dietary fat alone without reducing calories is insufficient


• High in Fiber– reduces CHD & cancer risks

– reduces caloric density

• Low in Sugar– reduces caloric density

– often associated with high fat foods


• Moderation in salt and alcohol– reduces hpt, CHD, cancer risks

– alcoholic beverages high caloric density

Findings RCT – Atkin’s Diet

• AHA step 1 diet– Wt loss = 20 lbs– LDL-C = no change– TG = 22% drop– HDL-C = unchanged

• Atkins Diet– Wt loss = 31 lbs– LDL-C = no change– TG = 49% drop– HDL-C = 11%

increase– Fewer drop-outs

A Low-Carbohydrate as Compared with a Low-fat Diet in Severe Obesity.

Samaha et al. NEJM 348:2074-81(2003)

• 132 severely obese (BMI=43)

• Randomly assigned to low-CHO or low- Fat diets for six months

• Weight loss at 6 months:– Low-fat: 1.9kg– Low-CHO: 5.8kg

• Triglyceride change– Low fat: -7mg/dl– Low cho: -38 mg/dl (p<.001)

• LDL-C– Low fat: + 3mg/dl– Low cho: + 5mg/dl (ns)

• HDL-C– Low fat: - 1mg/dl– Low cho 0 mg/dl (ns)

• Hemoglobin A1c– Low fat: 0%– Low cho: -0.6% (p=.06)

• Dietary changes– Caloric intake

• Low fat: -271 Cal/day• Low cho: -460 Cal/day (ns)

– Fat intake (% of calories)• Low fat: 33% to 33%• Low cho: 33% to 41% (p<.001)

• Drop-out rate at 6 months– Low fat: 47%– Low cho: 33% (ns)

Treatments for Overweight and Obese Clients Dr. David L. Gee FCSN/PE 446 Nutrition, Weight Control &...

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