Sue Cummings, MS, RD

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1 Starting Principles: Causes of Obesity Obesity is a chronic disease that is: Dietary Causes of Weight Regain SUE CUMMINGS, MS, RD SCUMMINGS1@PARTNERS.ORG both biopsychosocially complex in its origins and clinically diverse in its presentation Susceptibility to obesity and its associated risks vary greatly from one person to the next within obesogenic environments BMC Med. 21; 8: 88. Starting Principles Body energy storage is maintained at a set level through a complex weight regulatory system. Deviations from the preferred set level are resisted and minimized by a complex feedback control system Defense against Starvation Our bodies seek a Stable Adipose Tissue Mass not unlike body temperature, blood volume Diet-induced weight loss is accompanied by physiological adaptations which encourage weight regain Clinical Science (213) 124, Priya Sumithran and Joseph Proietto Gut: Brain Axis Gut messengers involved in Weight Regulation Gastrointestinal Track is the largest endocrine organ in the body. Clinical Science (213) 124, Priya Sumithran and Joseph Proietto 1

2 Amylin Ghrelin PYY CCK Key Hormone Changes Associated with Weight Loss and Regain Gut Hormone Changes Persistently Oppose Dietinduced Weight Loss Hormone Source Normal function Cholecystokinin (CCK) Duodenum Suppress appetite Ghrelin Gastric fundus Stimulate appetite, particularly for highfat, high-sugar foods Glucagon-like peptide 1 (GLP-1) Ileum Suppress appetite and increase satiety Peptide YY (PYY) Distal small intestine Suppress appetite Amylin Pancreas slowing gastric emptying and promoting satiety Leptin Adipocytes Regulate energy balance Suppress appetite Sumithran et al. NEJM 211; 365: Sumithran P, Proietto J. Clin Sci (Lond). 213;124: Mechanisms of Weight Loss By Manipulating the GI Tract, the weight loss surgery procedures alter secretion of gut hormones that play a role in weight regulation Bariatric procedures, by restructuring the gut: Influence the body weight regulatory system gut hormones, neural messaging and gut microbiota new defended body weight (new set point) all mechanisms not known: decreased hunger, increased satiety, defense of lbm, energy expenditure (Hao X, et al. Obesity, Feb. 216) GI Endocrine Responses to RYGB Weight Loss Surgery: Opposite of Restrictive Dieting Active GLP-1 (pg/ml) Acylated Ghrelin (pg/ml) GLP-1 5 min mixed meal RYGB Sham Lean Time after start of meal (min) Ghrelin 5 min mixed meal 3 RYGB Sham 25 Lean # PYY (pg/ml) PYY 5 min mixed meal 3 RYGB 25 Sham Lean Time after start of meal (min) Active Amylin (pg/ml) Amylin 5 min mixed meal Time after start of meal (min) Energy expenditure Microbiota Diet RYGB Appetite Hunger Satiety Gut peptides Ghrelin GLP-1, PYY, CCK, amylin Time after start of meal (min) Shin et al., 21 2

3 Effective treatment: changes set point Effective treatment changes set point Dieting Dieting Rebound higher weight Effective treatment changes set point Effective treatment changes set point Dieting rebound Healthy lifestyle Healthy lifestyle Medication + Healthy lifestyle Effective treatment changes set point Healthy lifestyle Medication + Healthy lifestyle Obesity is a Heterogenetic Disease Despite the profound effects of bariatric surgery on energy balance and glucose homeostasis, outcomes in individual patients vary widely. Most patients will not lose 1% of excess weight Therefore, it is important to manage expectations both in terms of amount of weight loss and weight regain Surgery + Healthy lifestyle 3

4 Weight Loss Outcomes of Bariatric Procedures % of Initial Weight Loss (% excess weight loss) Weight Loss Variability Every bariatric procedure studied demonstrates similar wide variations in outcome among patients. Procedure 2 Years 1 Years Adjustable gastric banding1 2% (4) 14% (28) Sleeve gastrectomy 2 25% (5) No data Roux-en-Y Gastric Bypass 1 35% (7) 25% (5) 1. Sjostrom L, Narbro K, Sjostrom CD, Karason K, et al. N Engl J Med 27;357: Diamantis T, Apostolou K, et alsoards 1 (214) ) RYGB SG Managing Weight Loss Expectations Inadequate Weight Loss: Failure to achieve and maintain expected weight loss after a bariatric procedure (<2%) Gastric Bypass Sleeve Gastrectomy GS: Definition for inadequate weight loss was EWL< 42%. Implications: Inadequate Weight Loss Inadequate Weight Loss: a failure to lose significant weight despite the major anatomic and physiological effects of surgery Inadequate weight loss is a biological event Not always predictable Requires careful assessment and varied approaches Aim of treatment is to enhance set point Optimization of life style/environment is essential May require conversion surgery Combination Therapies Addition of pharmacological therapies may be effective Weight Loss and Regain Even in those patients who have significant weight loss; weight regain occurs in variable amounts READY TO GO BACK? 4

5 Percent Total Weight Loss Weight loss and Regain expectations Swedish Obesity Subjects Diabetes Prevention Program Lifestyle & Medications Gastric Banding Gastric Bypass 15-25% of the lost weight regained over a period of 1 years Time After Surgery (years) Swedish Obesity Subjects: Diabetes Prevention Program Gut Hormones Oppose Diet-induced Weight Loss Case Study: Meet Ira Pre-op 1 year post-op (hooray!) 2.5 years post-op (worry) Excellent Poor Degree of Control Slide used with permission from Lee Kaplan, MD, PhD Environmental Modulators of Energy Balance Causes of weight regain should be fully evaluated Anatomical Clinical Factors Physiological Nutrition / Behavioral Gastric Bypass G-G fistula Pouch Enlargement G-J Anastomosis Dilation Gastric Banding Band Migration Band Loosening 5

6 Life Style Influences: Amenable to Change Post-Operative Eating behaviors Inadequate physical activity Processed diets Irregular eating pattern Inadequate sleep Stress Weight increasing medications Life changes (aging, pregnancy, menopause) Increased stress and pace of life Chaotic eating patterns Skipped meals Unhealthier food choices Does meal timing influence weight Disruption of circadian clocks by genetic and/or environmental factors precipitate numerous common disorders, including Obesity. Diet-induced thermogenesis (DIT) 5% lower in circadian evening than morning Theoretically can contribute to positive energy balance when eating is late Gamble, K. L. et al. (214) Circadian clock control of endocrine factors Nat. Rev. Endocrinol. doi:1.138/nrendo Morris et al, Obesity, 215 Circadian Rhythm Multiple genes and hormones that are involved in energy regulation and nutrient metabolism display rhythmic oscillations Shift workers have higher rates of obesity (police, airline personnel, healthcare providers, etc) Ghrelin Cortisol INCREASED APPETITE Stress There is significant evidence suggesting potentially detrimental effects of stress on Increased binge eating Eating patterns (skipping meals) Increased preference and consumption of HIGHLY PALATABLE (high sugar/fat/salt) Leptin Stress as a Common Risk Factor for Obesity and Addiction Sinha, Rajita, Biological Psychiatry, Volume 73, Issue 9, Brunner EJ, et al Am J Epidemiol, 28:165: Adam TC, Epel ES. Physiol Behav. 28;91(4): Evans GW, et al Pediatrics.212;129(1):e

7 Stress Increased Cortisol Insulin resistance Hyperinsulinemia Leptin Resistance Dietitian can address: Eating patterns structure; planning, preparing Healthier Foods 1. Address Barriers to making Life Style changes 2. Provide patient with tools/techniques Teaching how to reduce/manage Stress Decreased Metabolic Rate and Increased Food Intake Increased Hedonic Drive and Consumption of Palatable Foods Sinha R, Jastreboff AM. Biol Psychiatry. 213; 73(9): Post Op Triggers to weight regain Post-Operative Hypoglycemia Reactive hypoglycemia: Late dumping which occurs 1-3 hours after eating. Symptoms are related to (low blood sugar) which include sweating, shakiness, loss of concentration, hunger, and fainting or passing out. Dumping Syndrome: Occurs within minutes or up to an hour within eating Manage with dietary manipulation 6 small meal; protein source at each Avoid high sugar/refined carbohydrate foods. Mallory et al Obes Surg 25 Protein Distribution throughout Meals OPTIMAL DISTRIBUTION B L D Equal Distribution of Protein at meals stimulates muscle protein synthesis to maximal extent Ghrelin: Suppressed Longest by Protein Protein high satiety value Increased diet induced thermogenesis Enhanced glycemic control 3g/meal protein, suppress ghrelin Avoid excessive hunger Millward DJ, Layman DK, Tme D, Schaafsma G. Protein quality assessment: impact of expanding understanding of protein and amino acid needs for optimal health Am J Clin Nutr May 28 vol. 87 no S-1581S. Foster-Schubert et al. JCEM. 28; 93(5): Lomenick et al. JCEM. 29; 94(11):

8 Low calorie breakfast vs. high calorie dinner High Calorie Breakfast: (PROTEIN/CHO) Increased adherence to calorie reduced diet resulting in hunger suppression and better weight loss maintenance Probe for life style factors that may influence body weight: A. Eating the majority of calories in late evening B. Skipping breakfast and eating a high calorie, high fat dinner meal C. Working night or graveyard shift Jakubowicz, D., Barnea, M., Wainstein, J. and Froy, O. (213), High Caloric intake at breakfast vs. dinner differentially influences weight loss of overweight and obese women. Obesity, 21: doi:1.12/oby.246 Gut Microbiota Play an important role in: regulation of energy balance and development and progression of obesity Gut Microbiota differ between individuals who are lean and individuals with obesity. Bypass and Sleeve: Alter Microbiota RYGB and SG in a mouse model alters the microbiota independent of weight loss Microbiota altered by RYGB and SG contribute to several metabolic outcomes that influence: body weight adiposity lipids insulin Liou A, Kaplan LM et al., Sci Transl Med 213 Post-Op Regain: Is it More than Just Calories? High consumption of: o red and processed meat o sugary desserts and drinks o high fat foods o refined grains Associated with: o o significant increase in the relative abundance of Firmicutes (unfavorable); and significant decrease in the proportional representation of members of the Bacteroidetes (favorable) Does What we eat Matter? Is It more than Calories? High Healthy consumption diet of: red Prebiotics, and processed Probiotics meat sugary desserts and drinks High refined food diet, low fiber Environmental Factors 8

9 Post-surgery Regain Therefore, a low fat, high fiber diet of whole foods may be important to maintain the healthy microbial environment created by weight loss surgery. Weight Regain and Inactivity Epidemiologic, cross-sectional, and prospective correlation studies suggest an essential role for physical activity in weight-loss maintenance prospective trials shows a clear dose response relationship between physical activity and weight maintenance. Individual specific factors age, sex, amount of weight lost current body weight ethnicity genetic differences Behavioral Reduced physical activity Mozaffarian, NEJM, 211 Summarizing Address environmental triggers to weight regain stress management sleep hygiene chaotic meal / snack patterns An individualized diet is the basis of the dietary component of a comprehensive weight management program.. focus on real food vs high consumption of food like intake Consumption of greater energy intake at breakfast and lunch may be preferable to evening consumption. Protein intake distributed throughout day at meals/snacks (~3 g/meal) THANK YOU QUESTIONS? 9

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