Achievable Dietary Approaches to Prevent Weight Gain and Promote Health in Midlife Women Barbara J. Rolls, Ph.D.

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1 Achievable Dietary Approaches to Prevent Weight Gain and Promote Health in Midlife Women Barbara J. Rolls, Ph.D. Department of Nutritional Sciences The Pennsylvania State University

2 Dietary approaches to obesity have focused on the proportions of macronutrients Protein The proposed satiety hierarchy fructose fiber Carbohydrate sucrose Fat

3 On a reduced-calorie diet the proportions of fat, carbohydrates, and protein had little impact on weight loss over two years Sacks, et al., New England Journal of Medicine, 360: , 2009

Meta Analysis Comparison of Weight Loss Among Diet Programs 48 randomized trials; N=7,286 overweight or obese persons 25 of the studies examined weight loss at one year (n=5,000) Low-fat diets Ornish

4 Meta Analysis Comparison of Weight Loss Among Diet Programs 48 randomized trials; N=7,286 overweight or obese persons 25 of the studies examined weight loss at one year (n=5,000) Low-fat diets Ornish ~ 60 kcal CHO / 10-15% kcal PRO / 20% kcal FAT Low-carb diets Atkins, South Beach, Zone 40% kcal CHO / 30% kcal PRO / 30-55% kcal FAT 6 Months 12 Months 7.99 kg 7.27 kg 8.73 kg 7.25 kg CONCLUSION Weight loss differences between individual diets were small Need to find ways to enhance adherence to a healthy diet Johnston BC, et a. JAMA, 312: , 2014

5 Can we leverage eating behaviors to influence satiety, energy intake, and body weight? Portion size Variety Palatability Energy Intake Energy density (kcal/g) Availability

, 2004 Geier, et al., 2006 Fisher et al.

, 2005 Fruits and Vegetables Spill et al.

6 Amorphous Entrées Engell et al., 1995 Rolls et al., 2000 Fisher et al., 2003 Rolls et al., 2004 Kral et al., 2004 Fisher, 2007 Unit Foods Rolls et al., 2004 Geier, et al., 2006 Fisher et al., 2007 Big portions = Big intake Beverages Flood et al., 2006 Rolls, Roe, Meengs, 2007 Snacks Rolls et al., 2004 Raynor et al., 2007 Wansink et al., 2001 Wansink et al., 2005 Fruits and Vegetables Spill et al., 2010, 2011 Rolls et al., 2010 Mathias et al., 2011 Kral et al., 2010 Rolls et al., 2010 Naturalistic settings Fisher et al., 2003 Dilberti et al., 2004 Wansink et al., 2001 Wansink et al., 2005

7 Does our biology help us to resist the effect of portion size on intake? Breakfast Lunch Dinner + Afternoon snack 100% portions 150% portions + Evening snack

8 The effect of portion size on intake was sustained for 11 days Cumulative energy intake (kcal) Men 150% portions Men 100% portions Women 150% portions Women 100% portions Mon Tue Wed Thu Study day Rolls, Roe, & Meengs, Obesity, 15: , 2007 Fri Sat Sun Mon Tue Wed Thu 4606 ± 771 kcal 5027 ± 735 kcal

9 Prevalence of weight control strategies among obese NHANES participants trying to lose weight (n = 2523) Nicklas et al., Am J Prev Med, 42: , 2012

10 2010 guidelines emphasize portion control, but it is not clear how to do this or what the impact will be

11 Eat Less could mean a plate half empty You can have a full plate when cutting calories Higher ED Higher ED Lower ED From the Ultimate Volumetrics Diet, Morrow, calories 400 calories 400 calories The key is to lower the energy density (ED)

12 Dietary patterns can be very different even when calories and macronutrient proportions are similar ED = 0.7 ED = grams 320 grams Each tray contains: 475 kcal 10% protein 60% carbohydrate 30% fat

13 Macronutrients can influence intake through their effects on energy density (ED) Fat reduction can have a large effect on ED Water incorporation has the biggest impact on ED Water lowers ED even of high-fat foods Water can come from vegetables and fruits Fat Carbohydrates & Protein Water in food 9 kcal/g 4 kcal/g 0 kcal/g

14 Filling up first How to have an extra course and eat less First course Main course

Eat soup Consume water in food, not just as a beverage Enhance soup with veggies & beans (for fiber) and lean protein Clinical trials show soup aides weight

15 Eat soup Consume water in food, not just as a beverage Enhance soup with veggies & beans (for fiber) and lean protein Clinical trials show soup aides weight loss Rolls, et al., American Journal of Clinical Nutrition, 70: , 1999 Rolls BJ, Roe LS, Beach AM, Kris-Etherton PM. Obesity Research, 13, , 2005

Rolls, Roe, & Meengs, J Am Dietetic Assn, 104: 1570-1576, 2004 Eating a large low-energy-dense salad reduced energy

16 Rolls, Roe, & Meengs, J Am Dietetic Assn, 104: , 2004 Eating a large low-energy-dense salad reduced energy intake at lunch compared with no salad kcal No change kcal 100 kcal 200 kcal 400 kcal Keep total salad calories low

17 Whole fruit increases satiety more than pureed fruit or juice Apple juice with fiber Apple juice Whole apple Applesauce Flood-Obbagy & Rolls, Appetite, 52: , 2009

for those higher in energy density Puréed or chopped

18 How to fill your plate during the main course Reduce the energy density of meals by substituting water-rich ingredients for those higher in energy density Puréed or chopped vegetables and fruit can be incorporated into many recipes For 325 calories:

19 What is the effect of varying energy density when macronutrient proportions are kept constant? Palatability was similar across conditions Bell et al., Am J Clinical Nutrition, 67: , 1998

20 Adults ate a consistent weight of food and fewer calories when ED was reduced Food intake (g) Energy intake (kcal) Food intake (g) High Energy Density Med. Energy Density Low Energy Density Energy intake (kcal) High Energy Density Med. Energy Density Low Energy Density b a a b a a b a a b a a b a a c b a b a a 0 0 B L D S B L D S B L D S B L D S Day 1 Day 2 Day 1 Day 2 Meals Meals Bell et al, Am J Clinical Nutrition 67: , 1998

Combining reductions in energy density and portion size has substantial effects on calorie intake Smaller portion Bigger portion Smaller portion Bigger

21 Combining reductions in energy density and portion size has substantial effects on calorie intake Smaller portion Bigger portion Smaller portion Bigger portion Lower density Lower density Higher density Higher density Learn to modify your favorite foods Rolls, Roe & Meengs, Am J Clinical Nutrition, 83: 11-17, 2006

5 Two strategies for eating 1600 kcal during a day 2260

22 Can we use what we know about energy density to design diets that facilitate weight management? 590 grams Food ED = 2.5 Two strategies for eating 1600 kcal during a day 2260 grams Food ED = 0.7 Rolls, The Ultimate Volumetrics Diet, Morrow, 2012

23 How do two strategies to reduce the energy density of the diet affect weight loss? RF Group: Reduce fat intake and restrict portions RF + FV Group: Increase intake of high-water/high-fiber foods Vegetables, fruits, soups Emphasize portion control only for energy-dense foods High-fat foods and foods with low moisture content Neither group counted calories or fat grams

24 Both groups were successful, but the RF + FV group lost more weight 2 Phase 1 Phase 2 4 Change in body weight (kg) Duration (months) p < 0.04 p < RF group (n = 36) RF+FV group (n = 35) Change in body weight (lb) Ello-Martin et al., Am J Clinical Nutrition, 85: , 2007

25 Weight loss was related to change in food ED over 6 months in the PREMIER (DASH) trial Small decrease in ED or increase in ED (n = 219) Modest decrease in ED (n = 220) Large decrease in ED (n = 219) Change in Food Weight Change in Energy Intake Change in Body Weight Food weight (g/d) Energy intake (kcal/d) Body weight (lb) Ledikwe et al., Am J Clinical Nutrition, 85: , 2007

26 Strategies that focus on energy density can also help to prevent weight regain after weight loss 7 6 Weight change (kg) Control Energy density + meal replacement Meal replacement Energy density Follow up month Lowe et al., Obesity, 22: , 2014

An emphasis on energy density fits with guidance from most major health organizations They emphasize portion control for energy-dense foods They suggest eating a

for food providers and acceptable and affordable for consumers 293 calories 607 calories http://www.cdc.gov/nccdphp/dnpa/nutrition/pdf/energy_density.

27 An emphasis on energy density fits with guidance from most major health organizations They emphasize portion control for energy-dense foods They suggest eating a greater variety of low-ed nutrient-rich food Strategies are needed that will facilitate substitution of lower-ed foods for high-ed foods These must be feasible for food providers and acceptable and affordable for consumers 293 calories 607 calories Perez-Escamilla, et al., J Acad Nutr & Dietetics, 112: ,

28 HarperTorch 2003 HarperCollins, 2007 Morrow, 2012

Jennifer Orlet Fisher, PhD Department of Public Health Center for Obesity Research and Education Temple University

Moving towards healthier food portion sizes Jennifer Orlet Fisher, PhD Department of Public Health Center for Obesity Research and Education Temple University Introduction of large portions coincides with