Dietary treatment of obesity-what is new? Maria Hassapidou Professor of Nutrition and Dietetics ATEI Thessaloniki, Greece

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1 Dietary treatment of obesity-what is new? Maria Hassapidou Professor of Nutrition and Dietetics ATEI Thessaloniki, Greece

2 Let food be thy medicine and medicine be thy food. Hippocrates Aphrodite of Willendorf (23000 bc, paleolithic era)

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4 About 39% of women and 21% of men in Western countries are trying to lose weight.

5 P e r c e n ta g e o f H ig h S c h o o l S tu d e n ts W h o W e r e T r y in g T o L o s e W e ig h t, b y S e x * a n d R a c e /E th n ic it y,* * Percent T o ta l F e m a le M a le W h ite B la c k H is p a n ic * F > M * * H > W > B N a tio n a l Y o u th R is k B e h a v io r S u rv e y,

6 Desire of the children to lose weight according to their BMI BMI Adolescents who wanted to increase their weight (%) Adolescents who wanted to keep their weight (%) Adolescents who wanted to lose weight (%) underweight normal overweight Hassapidou M., Pangalos G., Papadopoulou S,K., Kugiumtzis D. (2006). Obesity prevalence, dieting status and food choice criteria in adolescents in Thessaloniki, Greece: results from database Processing and analysis. Obesity Reviews, 7(2), 352.

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8 The dietary treatment of obesity is a part of a comprehensive program of weight control that includes increased physical activity, lifestyle modification, appropriate intakes of nutrients to minimize chronic disease risk, and eating patterns that maximize quality of life.

9 Chronic dieters tend to be food-preoccupied, distractible, emotional, binge-prone, and unhappy, particularly when the diets are very restrictive. It is thus important to foster a healthy, balanced, stable relationship with food and diet. Health professionals can play a vital role in helping patients develop such a relationship.

10 Set goals Clarify reasonable goals Adapt realistic goals that include Health objectives Define Successful outcomes for weight reduction with the patient Define dieting success in broader terms than weight loss alone Set an Individualized Healthier weight target with the patient Reasonable target:10% loss of BW over 6 months Set an Increased Physical activity goal Individualize the Diet and treatment program

11 Calorie deficit diets Low calorie diets(lcds): Kcals for women, Kcals for men Very low calorie diets(vlcds):<800 KcalsVLCDs supply 800 calories or less, a total of 50 to 80 grams of protein, 100% of the Reference Daily Intake (RDI) for vitamins and minerals per day, and are designed to produce very rapid weight loss while still preserving lean body mass. VLCDs are prescribed as a form of intensive diet therapy, which require close medical supervision, and should not be used long-term. They are intended to induce quick and significant weight loss of about 14 to 21 kilograms over a short time (11-14 weeks). VLCD s are sometimes used to provide a jump-start to further obesity treatment.

12 VLCD s vs LCD s: Meta-analysis of 6 RCTs Trials with direct comparisons Short-term: mean 12.7 weeks Long-term: mean 1.9 years Weight loss (as % of initial weight): short-term long-term LCDs VLCDs (p) (0.001) (0.2) Tsai and Wadden, Obesity, 2006

13 Formula Diets No change in habits are observed. Possibly leading to increased chance of relapse Expensive Examples: HMR,Optifast,Medifast

14 Dietary strategies identified by an expert panel as having sufficient evidence to recommend for weight loss (Jensen MD. Expert panel report: Guidelines (2013) for the management of overweight and obesity in adults. Obesity 2014) Lacto-ovo-vegetarian High protein (30%) Zone-type (40% carbohydrate) with 5 meals daily European Association for the Study of Diabetes Guidelines Low carbohydrate (initially <20g/day) High protein (25%) moderated carbohydrates (45%) Low glycemic load Low fat (10-25%) Moderate protein (12%), higher carbohydrate (58%) Low fat (<30%), high dairy & fiber Low fat (~20%) Mediterranean-style AHA-style step 1

15 Macronutrient distribution Low or Restricted-Carbohydrate Approaches Low fat High protein Low glycemic load

16 American Journal of Clinical Nutrition, Vol. 88, No. 1, 1-11, July 2008

17 Examples of: Low or Restricted Carbohydrate Approaches Dr. Atkins Sugar Busters Carbohydrate Addicts Diet The Five-Day Miracle Diet Protein Power Enter the Zone Endocrine Control Diet Healthy For Life Scarsdale medical diet

18 Atkins Diet High protein, high fat, and low carbohydrates which causes rapid initial weight loss. Phases gradually work in a small amount of CHO s 60 % fat/ 30% protein/ 10% CHO Eliminates: fruits, cereals, breads, grains, starches, dairy products, and starchy vegetables Side effects: fatigue, muscle weakness, headaches, irritability, dizziness, constipation, halitosis (bad breath).

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20 The Effect of a Plant-Based Low-Carbohydrate ("Eco-Atkins") Diet on Body Weight and Blood Lipid Concentrations in Hyperlipidemic Subjects Jenkins DJA, Wong JMW, Kendall CWC, Esfahani A, Ng VWY, Leong TCK, Faukner DA, Vidgen E,Greaves KA, Paul G,Singer W. Arch Intern Med. 2009;169(11):

21 Low carbohydrate diets,ada recommendations

22 Low Fat Less than 20% of energy is coming from fat, usually only 5-10%. There is limited (or elimination of) animal protein sources; also all fats, nuts, and seeds. Dieters eat primarily grains, fruit, and vegetables, which most people cannot do for a very long time.

23 Examples of: Low Fat Diet Plans The Rice Diet Report The Macrobiotic Diet (some versions) The Pritikin Diet Eat More, Weigh Less The 35+ Diet 20/30 Fat and Fiber Fat to Muscle Diet T-Factor Diet Fit or Fat Two Day Diet Complete Hip and Thigh Diet The Maximum Metabolism Diet The Pasta Diet G-Index Diet Lean Bodies Outsmarting the Female Fat Cell

24 <5 % difference in % E FAT 5-10 % difference in % E FAT % difference in % E FAT >15 % difference in % E FAT

25 .Nordmann AJ, Nordmann A, Briel M, Keller U, Yancy WS,Brehm BJ, Bucher HC. Effects of lowcarbohydrate vs. low-fat diets on weight loss and cardiovascular risk factors. A metaanalysis of randomized controlled trials. Arch Intern Med 2006;166:

26 Arch Intern Med 2006;166:

27 Arch Intern Med 2006;166:

28 Dansinger ML, Gleason JA, Griffith JL, Selker HP, Schaefer EJ. Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial. JAMA 2005;293: Higher loss with the Atkins diet sustained adherence to a diet, rather than diet type, predicted weight loss and reduction of cardiac risk factors.

29 Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial. Gardner CD, Kiazand A,Alhassan S, Kim S,Stafford RS, Balise RR, Kraemer HC, King AC. JAMA Jul 11;298(2):178.

30 Figure 1. Weight Change Relative to Baseline JAMA Jul 11;298(2):178

31 Conclusions: In this study, premenopausal overweight and obese women assigned to follow the Atkins diet, which had the lowest carbohydrate intake, lost more weight at 12 months than women assigned to follow the Zone diet, and had experienced comparable or more favorable metabolic effects than those assigned to the Zone, Ornish, or LEARN diets While questions remain about long-term effects and mechanisms, a low-carbohydrate, high-protein, high-fat diet may be considered a feasible alternative recommendation for weight loss.

32 Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates Frank M. Sacks, M.D., George A. Bray, M.D.et al N Engl J Med Volume 360(9): February 26, 2009 N Engl J Med February 26, 2009 N Engl J Med Volume 360(9): February 26, 2009

33 Mean Change in Body Weight and Waist Circumference from Baseline to 2 Years According to Dietary Macronutrient Content Sacks FM et al. N Engl J Med 2009;360:

34 Conclusion of the study Reduced-calorie diets result in clinically meaningful weight loss regardless of which macronutrients they emphasize

35 Fad Diets Dr. Abravenel s Body Type and Lifetime Fit for Life Dr. Berger s Immune Power Diet The Hilton Head Metabolism Diet The Beverly Hills Diet Dr. Debetz Champagne Diet Sun Sign Diet Eat to Win Cabbage-Soup Diet Eat Great, Lose Weight The Ultrafit Diet Two Day Diet Paris Diet Eat Right 4 Your Type 3 Season Diet Metabolize

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37 Mediterranean Diet and Weight Loss: Meta-Analysis of Randomized Controlled Trials Katherine Esposito, Christina-Maria Kastorini, Demosthenes B. Panagiotakos, Dario Giugliano. Metabolic Syndrome and Related Disorders. February 2011, 9(1): 1-12

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39 Shai I, Schwarzfuchs D, Henkin Y, Shahar DR, Witkow S, Greenberg I,et al. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med 2008;359: A comparison of three diets, low-carbohydrate unrestricted energy, Mediterranean restricted energy, and low-fat restricted energy, on weight loss in moderately obese subjects over 2 y demonstrated significant decreases in body weight, blood pressure, and waist circumference with all diets; however,these were greater on the low-carbohydrate and Mediterranean diets than on the low-fat diet. Concomitant improvements in lipid profiles αnd other markers were also more favorable on the low-carbohydrate and Mediterranean diets

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41 The protective role of the mediterranean diet on the prevalence of metabolic syndrome in a population, of Greek obese subjects. Paletas K, Athanasiadou E, Sarigianni M, Paschos P, Kalogirou A, Hassapidou M, Tsapas A..J Am Coll Nutr.,2010,Feb,29(1)41-5 OBJECTIVE: The aim of the study was to evaluate and analyze the dietary habits in a population of Greek overweight and obese subjects and to investigate the potential associations between those patterns and the prevalence of metabolic syndrome components. METHODS: The study recruited 226 consecutive adult (30 men, 169 women) overweight or obese (body mass index >25 kg/m(2)) individuals attending the Metabolic Diseases Unit. Medical history, dietary history, and anthropometric parameters were recorded during the first visit. Fasting blood samples were collected for biochemistry assaying.

42 RESULTS: According to the nutrient intake history and Mediterranean Diet Scale (MDS), participants were divided into 3 groups: those adhering to the MD and those not following the MD, who were further subdivided into the high-carbohydrate (HC) and high-fat (HF) diet groups according to the source of maximum energy intake. Adherence to the MD was associated with a lower prevalence of metabolic syndrome (27.3%, 69.2%, and 60.4% in MD, HC, and HF respectively, p = 0.006), lower low-density lipoprotein cholesterol (p = 0.009, MD vs. HF), and lower postchallenge glucose values (p = 0.028, MD vs. HF). CONCLUSIONS: Adherence to the MD seems to be declining among Greek overweight and obese subjects, a phenomenon that is associated with an increase in the prevalence of the metabolic syndrome.

43 DIETARY INTERVENTION PROGRAM IN GREEK MUNICIPALITIES FOR OBESE PATIENS ΣΥΜΜΑΧΙΑ ΓΙΑ ΤΗΝ ΥΓΕΙΑ NUTRIHEAL Anthropometric and metabolic parameters before and after intervention (duration of 6 months) N=3681 Intervention Group (Ι) Before After p ΒΜΙ 33.1 ± ±6.3 < % Body Fat 39.7± ±8.0 < W (cm) 103.3± ±14.8 < LDL-C (mg/dl) ± ± 35.0 < FPG(mg/dl) ± ±23.5 < SBP (mmhg) ± ±12.9 < 0.001

44 DIETARY INTERVENTION PROGRAM IN GREEK MUNICIPALITIES FOR OBESE PATIENS ΣΥΜΜΑΧΙΑ ΓΙΑ ΤΗΝ ΥΓΕΙΑ NUTRIHEAL N=3681 Percentage of significant mean difference between groups (I) and (C) Percentage of mean difference p ΒΜΙ - 3.0% < % Body Fat - 3.1% < W (cm) % < LDL-C (mg/dl) - 5.8% < FPG(mg/dl) - 3.4% 0.01 SBP (mmhg) - 1.0% 0.002

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46 Before and After the Diet Before After After The After

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54 DIET BEFORE AND AFTER SURGERY Stage 1 Half glass of water per hour, typically in the hospital on the day of surgery Stage 2 Non-caloric clear liquids, usually in the hospital the day after surgery (e.g., sugar-free Jell-O, flat diet soda, diet juice) Stage small meals per day, each consisting of a high-protein, no added sugar shake, such as Isopure or Sugar-Free Carnation Instant Breakfast Water or non-caloric, non-carbonated clear liquids between meals Goals of this stage are to drink 8 glasses of water per day grams of protein a day for women and grams of protein per day for men This stage lasts 2-3 weeks Stage 4 Small portions of moist, ground/pureed foods. Begin supplementing with a multivitamin plus minerals, Vitamin D with calcium (specifically calcium acetate), and sublingual Vitamin B 12 Aim for grams of protein per day This stage lasts 4-5 weeks Stage 5 Small portions of low-fat (<3-5 grams per serving) or low-sugar (<14 grams per serving) solid foods At least 64 ounces of fluid per day,aim for grams of protein,continue to take supplements Follow this 6-8 weeks after surgery and follow up with a Registered Dietitian Dietary Treatment of Obesity,Johanna T Dwyer, Kathleen J Melanson,, Utchima Sriprachyanunt, Paige Cross, and Madelyn Wilson.Endotext [Internet], February 28, 2015

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57 We are still Looking for the Magic!

58 Thank you