F41: Obesity Treatment 2018: Behavioral and Nutrition Tools, Pharmacology, Endoscopic and Bariatric Procedures

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1 F41: Obesity Treatment 2018: Behavioral and Nutrition Tools, Pharmacology, Endoscopic and Bariatric Procedures Behavioral and Medical Nutrition Therapy for Obesity Caroline M. Apovian, MD, FACN, FACP President, The Obesity Society Professor of Medicine and Pediatrics Boston University School of Medicine Director, Nutrition & Weight Management Center Section of Endocrinology, Diabetes, and Nutrition Boston Medical Center May 18, :15 am 12:00 pm 1

2 Washington Post, January 7, 2016, Peter Whoriskey 2

3 Wide and Conflicting Array of Choices 3

4 Only 1 in 6 overweight and obese adults maintained weight loss of at least 10% for one year 1 Long term success rates may be even lower 2 1.NHANES ; Kraschnewski JL, Boan J, Esposito J, et al. Int J Obes (Lond). 2010;34(11): Douketis JD, Macie C, Thabane L, Williamson DF. Int J Obes (Lond). 2005;29(10):

5 Why is it so hard to lose weight and maintain weight loss? 5

6 Possible Causes of Poor Weight Loss Maintenance Adherence One explanation for the poor longterm outcome of weight loss diets relates to behavior: Motivation to adhere to restrictive regimens typically diminishes with time Hypothalamic Injury Weight loss elicits biological adaptations that promote weight regain: Specifically, a decline in energy expenditure (adaptive thermogenesis) and an increase in hunger Ebbling CB, et al. JAMA Jun 27;307(24):

7 DIRECT: Two year Results Dietary Intervention Randomized Controlled Trial n=272 completers Diet type and mean weight loss: Low fat: 3.3 kg Mediterranean: 4.6 kg Low carbohydrate: 5.5 kg Weight Loss 6 months Partial rebound and plateau Maintenance 18 months Shai I, et al. N Engl J Med. 2008;359:

8 DIRECT: Six year Follow up Dietary Intervention Randomized Controlled Trial year Total Weight LOSS P= kg 1.7 kg 3.1 kg 5.5 Schwarzfuchs D, Golan R, Shai I. N Engl J Med Oct 4;367(14):

9 Obesity Associated with Hypothalamic Injury in Rodents and Humans Rodent models of obesity, induced by consuming high fat diet (HFD), are characterized by inflammation both in peripheral tissues and hypothalamic areas critical for energy homeostasis Unlike inflammation in peripheral tissues, which develops as a consequence of obesity, hypothalamic inflammatory signaling was evident in both rats and mice within 1 to 3 days of HFD onset, prior to substantial weight gain Both reactive gliosis and markers suggestive of neuron injury were evident in the hypothalamic arcuate nucleus of rats and mice within the first week of HFD feeding Evidence of increased gliosis in the mediobasal hypothalamus of obese humans, as assessed by MRI Findings suggest obesity is associated with neuronal injury in a brain area crucial for body weight control in both humans and rodent models Thaler PT, et al. J Clin Invest Jan 3;122(1): doi: /JCI Epub

10 Hypothalamic Injury Diminishes Signaling to Cortex and NTS, Leading to Greater Weight Gain AGRP: agouti related peptide α MSH: α melanocytestimulating hormone GHSR: growth hormone secretagogue receptor INSR: insulin receptor LepR: leptin receptor MC4R: melanocortin 4 receptor NPY: neuropeptide Y POMC: proopiomelanocortin PYY: peptide YY Y1R; neuropeptide Y1 receptor Y2R: neuropeptide Y2 receptor Apovian CM, et al. J Clin Endocrinol Metab. 2015;100:

11 The Fat Trap 2009, 50 obese men and women Men 233 lbs/average Women 200 lbs/average Extreme low calorie diet Optifast shakes + 2 cups of low starch vegetables Total kcal/d for eight weeks At 10 weeks: 30 lb ave. weight loss At year one: 11 lb ave. weight regain Reported feeling more hungry and preoccupied with food than before the weight loss Sumithran P et al. N Engl J Med. 2011;365: Body continues to fight against weight loss long after dieting has stopped 11

12 Long Term Persistence of Hormonal Adaptations to Weight Loss Changes in Weight from Baseline to Week lb GAIN 30 lb LOSS 10 week weight loss program Sumithran P et al. N Engl J Med. 2011;365:

13 Sustained Changes in Peripheral Signals for Up to One Year Following Weight Loss Mean fasting and postprandial levels of some peripheral signals at baseline and 62 weeks Ghrelin, pg/ml Amylin, pg/ml Appetite Stimulating Hormone was Higher Week 62 Baseline Postprandial Time, min Appetite Suppressing Hormone was Lower Baseline Postprandial Time, min Week 62 Peptide YY, pg/ml CCK, fmol/ml (cholecystokinin) Appetite Suppressing Hormone was Lower Baseline Week Postprandial Time, min Appetite Suppressing Hormone was Lower Postprandial Time, min Baseline Week week, lifestyle based weight loss intervention in healthy overweight and obese adults (n=34) led to sustained elevations in appetite stimulating hormone(s) and decreases in appetite suppressing hormones Sumithran P et al. N Engl J Med. 2011;365:

14 Sustained Changes in Peripheral Signals for Up to One Year Following Weight Loss Mean fasting and postprandial ratings of hunger and desire to eat at baseline and weeks 10 and 62 Hunger Desire to Eat Changes were accompanied by significant increases in appetite based on self-reported ratings (P<0.001) Sumithran P et al. N Engl J Med. 2011;365:

15 Lower Calorie Needs Post Weight Loss May Promote Weight Regain Resting Energy Expenditure (REE) Refers to the number of calories required daily by the body to support the body s basic cellular processes 1 Typically comprises two thirds of a patient s total daily energy needs 2 Decreased REE was found to be a determinant of weight regain in one regression analysis from a long term dietary intervention (n=67 women) designed to maintain body weight after weight loss 3 Review of 90 publications (n=2996) from reported decreases in REE with weight loss 2 Mean daily decrease in REE: 15.4 ± 8.7 kcal/kg* body weight lost *1 kg=2.2 pounds. 1. Weigle DS. FASEB J. 1994;8(3): Schwartz A et al. Obes Rev. 2010;11(7): Pasman WJ et al. Obes Res. 1999;7(1):

16 Diets Which is Best? 16

17 Macronutrient Profiles of Popular Diets Fat gms de Souza RJ, et al. Am J Clin Nutr 2008;88:

18 Popular Diets vs. Recommendations AMDR for PROTEIN 18 Institute of Medicine's Acceptable Macronutrient Distribution Ranges (AMDR) upper and lower limits AMDDR for CHARBOHYDRATE AMDR for FAT de Souza RJ, et al. Am J Clin Nutr 2008;88:

19 Low Carb Diets Source of Calories or Caloric Intake? Systematic Review 107 articles from ,268 participants 5 studies > 90 days None were controlled trials Conclusion: Weight loss was principally associated with decreased caloric intake and increased diet duration, not reduced carbohydrates Insufficient evidence for recommendation for or against use of low carbohydrate diets Bravata DM, et al., JAMA Apr 9;289(14):

20 Weight Outcomes After Two Years on a Low Carbohydrate vs. Low Fat Diet Conclusion Successful weight loss can be achieved with a low fat or lowcarbohydrate diet when coupled with comprehensive behavioral treatment Foster GD, et al. Ann Intern Med August 3; 153(3):

21 POUNDS Lost, 2009 Preventing Overweight Using Novel Dietary Strategies Study Calories not Macronutrients Determine Weight Loss at Two Years N=811 Completers: 4 kg avg. wt loss N=645 CONCLUSIONS: Reduced calorie diets result in clinically meaningful weight loss regardless of which macronutrients they emphasize Sacks FM, et al. N Engl J Med Feb 26;360(9): Assigned Diets: 15 to 25% PRO 20 to 40% FAT 35 to 65% CHO (P>0.20) 21

22 POUNDS Lost, 2009 Preventing Overweight Using Novel Dietary Strategies Study No differences between diets in body composition, abdominal fat, or hepatic fat At 6 months (chart below) and at two years 25% 15% 40% 20% 65% 35% "This new information should focus weight loss approaches on reducing calorie intake rather than any particular proportions of fat, protein or carbohydrate." Frank M. Sacks, M.D. PI of POUNDS LOST and Professor of CVD Prevention, Harvard School of Public Health de Souza J, et al. Am J Clin Nutr Mar; 95(3):

23 Effects of Low Carbohydrate and Low Fat Diets Randomized Trial, n = 119 Completers, 12 months N = 60/82% low fat group <30% fat daily (<7% sat fat) 55% from carbs N = 59/79% low carb group <40 gm/day CONCLUSION: Low carbohydrate diet was more effective for weight loss and cardiovascular risk factor reduction than the low fat diet Total HDL Cholesterol Ratio % Fat Mass Triglyceride Level Body Weight 1.8 kg 3.5 kg p = kg 0.44 p = % p = mmol/l ( 14.1 mg/dl) p = Bazzano LA, et al. Ann Intern Med. 2014;161(5): doi: /m * P < 0.05 for between group difference 23

24 Key to Weight Loss: Diet Quality, Not Quantity DIETFITS Randomized Clinical Trial 12 mo Weight Loss by Diet and Genotype No significant difference in weight change between: ( 5.5kg) healthy low fat diet vs ( 6.0kg) healthy low carb diet Significant amounts of weight lost over the course of a year due to: Cutting added sugar, refined grains and highly processed foods Eating plenty of vegetables and whole foods without counting calories or limiting portion sizes Worked for those on low fat or low carb diets Not influenced by genetics or insulin response to carbohydrates Gardner CD, et al. JAMA. 2018;319(7):

25 High Protein Diets: Literature Overview Data suggest that higher protein diets provide improvements in appetite, body weight management, cardiometabolic risk factors, or all of these health outcomes gm protein/ kg of body wgt/per day gm protein per meal Leidy HJ, et al. Am J Clin Nutr 2015;101(Suppl):1320S 9S. 25

26 Look AHEAD Study Year 1 Year 8 Year 8 >10% weight loss 26.9% ILI (vs. 17.2% DSE) of initial weight (P < 0.001) Look Ahead Research Group. Obesity (Silver Spring) Jan;22(1):

27 Weight Loss Reduces Risk of Type 2 DM in Subjects with IGT 27 Da Qing IGT and Diabetes Study 1 (Diet and exercise) Finnish Diabetes Prevention Study 2 (Diet and exercise) US Diabetes Prevention Program 3 (Diet and exercise) Xenical in the prevention of Diabetes in Obese Subjects (XENDOS) study 4 (orlistat) Type 2 DM Risk Reduction 42% 58% 58% 37% DPP: lifestyle interventions are more effective than medications 3 1 Pan XR, et al. Diabetes Care. 1997;20: Tuomilehto J, et al. N Engl J Med. 2001;344: The DPP Research Group. N Eng J Med. 2002;346: Sjöström L, et al. Poster presented at the 9th International Congress on Obesity. São Paulo, Brazil, Torgerson et al. Diabetes Care 2004; 27:

28 Successful Long term Weight Loss 28

29 Look AHEAD Trial at 4 Years Initial Weight Loss Predicts Ultimate Success ILI participants who lost 10% at year 1 (N=887) ILI participants who lost 5.0% to 9.9% at year 1 (N=702) ILI participants who lost <5% at year 1 (N=729) % reduction in initial weight Years 3 4 N=88 (9.9%) N=174 (19.6%) N=251 (28.3%) N=374 (42.2%) Years 3 4 N=177 (25.2%) N=247 (35.2%) N=177 (25.2%) N=101 (14.4%) Years 3 4 N=325 (44.6%) N=245 (33.6%) N=107 (14.7%) N=52 (7.1%) 70% had >5% loss at 4 years Wadden TA, et al. Obesity. 2011;19(10): % had >5% loss at 4 years 22% had >5% loss at 4 years 29

30 Successful Long term Weight Loss National Weight Control Registry Ten Year NWCR Data 10,000 registrants N=2886 who lost 31 kg and maintained it for 5 years Maintaining 33 kg loss for 5 years Regain at end of 10 years but still lost 30% total body Eat 1800 kcal/day with 27% fat weight then gained to 22.6% total weight loss Perform 2700 kcal/week exercise 10 year loss = 23 kg 40% weigh themselves daily Weight regain levels out from 5 years to 10 20% weekly 85% of registrants lost 20% Reduced TV watching 40% of registrants lost 30% Limit diet variety If exercise < by 500 kcal per week they regain 9 kg 78% eat breakfast If exercise is maintained they regain only 4.5% or 4.5 kg Eat fast food once per week Use more artificially sweetened beverages than others of normal weight They are VIGILANT National Weight Control Registry 30

31 Maintaining Weight Loss National Weight Control Registry N=2886 Better long term outcomes with: Larger initial weight losses Longer duration of maintenance Mean weight loss: Baseline: 31.3 kg (95% CI=30.8, 31.9) 5 Years: 23.8 kg (95% CI=23.2, 24.4) 10 Years: 23.1±0.4 kg (95% CI=22.3, 23.9) Greater weight REGAIN associated with: Decreases in leisure time physical activity Decreases in dietary restraint Decreases in self weighing frequency Increases in percent of intake from fat and disinhibition >87% estimated to be maintaining >10% weight loss at Years 5 and 10 Thomas JG, Bond DS, Phelan S, Hill JO, Wing RR. Am J Prev Med Jan;46(1):

32 Weight Loss Research Long term treatment with regular support can be effective 1 5 Weight must be managed on an ongoing basis Elmer PJ, et al. Annals of Internal Medicine, 144: , Wadden TA. Annals of Internal Medicine, 119(7): , October Tate DF. JAMA, 289(14): , April Tate DF, Wing RR, Winett RA. JAMA 285(9): , March Ness Abramof R, Nabriski D, Apovian CM. The Israel Medical Association Journal, 6: , December Wadden TA, Brownell KD, Foster GD. Journal of Consulting and Clinical Psychology, 70(3): , Wadden TA, Foster GD, Letizia KA. Journal of Consulting and Clinical Psychology, 62(1): , Wadden TA, et al. Archives of Internal Medicine, 161: , Wadden TA, et al. NEJM, 353(20): , November

33 The Adherence Factor 33

34 Adherence Not Diet Predicts Success Consistent finding in four 2012 meta analyses, each summarizing 13 to 24 trials: adherence was most strongly associated with weight loss 1 4 Meta analysis 2014: 48 trials, n = 7,286; conclusion: any diet a patient will adhere to lose weight is best 5 1. Ajala O, English P, Pinkney J. Am J Clin Nutr Mar;97(3): Wycherley TP, et al. Am J Clin Nutr Dec;96(6): Hu T, et al. Am J Epidemiol Oct 1;176 Suppl 7:S Bueno NB, et al. Br J Nutr Oct;110(7): Johnston BC, et al. JAMA. 2014;312(9):

35 Comparison of Weight Loss Among Diet Programs in Overweight and Obese Adults, a Meta analysis 48 randomized trials, n = 7,000 overweight or obese persons 25 of the studies examined weight loss at one year, n = 5,000 Low fat diets Ornish, Rosemary Conley ~ 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 diets were small Any diet a patient will adhere to in order to lose weight is best Johnston BC, et a. JAMA. 2014;312(9): doi: /jama

36 Adherence Not Diet Predicts Success Comparison of Four Popular Diets Diet type does not predict weight loss Adherence predicts weight loss RESULTS: Amount of weight loss was associated with self reported dietary adherence level (r = 0.60; P<.001) but not with diet type (r = 0.07; P =.40) Dansinger ML, et al. JAMA Jan 5;293(1):

37 2013 Obesity Guidelines 37

38 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines and The Obesity Society July 1, 2014 J Am Coll Cardiol Jul 1;63(25 Pt B):

39 New Guidelines: Recommendations 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults Use BMI to identify risk; advise patients of their risk Use waist circumference to identify risk; advise patients of their risk 3% 5% sustained weight loss reduces risk factors and risk of diabetes Prescribe set number of calories per day There is no ideal diet Advise obese adults who meet criteria that surgery may be an option J Am Coll Cardiol Jul 1;63(25 Pt B): AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults 39

40 40 Highlights: 2013 Obesity Guidelines 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults 1. Use BMI to identify risk; advise patients of their risk 2. Use waist circumference to identify risk; advise patients of their risk 3. Prescribe set number of calories per day 4. There is no ideal diet 5. Advise a program with in person participation of >6 mo 6. Electronic and commercial programs can aid in weight loss 7. Regular contact is best for long term maintenance 8. For weight maintenance after weight loss: Engage in high levels of physical activity ( min/week) Monitor body weight regularly Consume reduced calorie diet J Am Coll Cardiol Jul 1;63(25 Pt B): AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults 40

41 Obesity Guidelines: Recommendation AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults Prescribe a diet to achieve reduced calorie intake for obese or overweight individuals who would benefit from weight loss, as part of a comprehensive lifestyle intervention. Any one of the following methods can be used to reduce food and calorie intake: 1,200 1,500 kcal/d for women 1,500 1,800 kcal/d for men (adjust for individual s body weight); 500 or 750 kcal/d energy deficit Prescribe set number of calories/day or calorie deficit/day Prescribe one of the evidence based diets that restricts certain food types (such as high carb foods, low fiber foods, or high fat foods) in order to create an energy deficit by reduced food intake J Am Coll Cardiol Jul 1;63(25 Pt B): AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults Choose an evidence based diet there is no ideal diet 41 41

42 SUMMARY: Conflicting Information: What s a Dieter to Do? Low carb and low fat diets are similar at one year Short term, low carbohydrate diets might lead to more rapid weight loss than other diets Protein is spared in a PSMF when ketone utilization in brain increases and demand for glucose diminishes, which together lead to protein sparing Individuals should choose the diet they can sustain into the future considering their lifestyle, taste preferences, and culture 2013 Obesity Guidelines do not recommend one diet over another High protein diets have a greater impact on fullness, are better for exercisers, and improve weight maintenance 42

43 CDC Recommendations for Physical Activity Adults 18 to 64 Years of Age Moderate Intensity Vigorous Intensity Strength Training 150 mins/week OR 75 mins/week OR 2 or more days/week 30 mins/day for 5 days 15 mins/day for 5 days Work all major muscles Make gradual, incremental changes Ultimate goal is 420 minutes/week of moderate intensity activity 43

44 Diet and Physical Activity for Best Results 0 Weight Loss/Gain (kg) Non exercise Exercise Treatment (wk) Follow up (mo) Balanced caloric deficit diet Protein sparing modified fast Adapted from Pavlou KN, et al. Am J Clin Nutr. 1989;49(5 Suppl):

45 2015 U.S. Dietary Guidelines 45

46 2015 Dietary Guidelines Cornerstone of U.S. federal nutrition policy, issued every 5 years since 1980 Key Recommendations, consume: <10% calories/day from added sugars <10% calories/day from saturated fats <2,300 milligrams/day sodium Alcohol in moderation >one drink/day for women >two drinks/day for men Limit: Saturated fats and trans fats Sodium Added sugars Beverages high in sugar New! Coffee: up to 5 cups/day OK Eggs: OK (no limit on cholesterol) No limit on total fat dietary guidelines americans summary/ 46

47 Summary Hypothalamic injury and decreased resting metabolic rate (REE) may be responsible for lack of weight loss success Most popular diets net similar results over time High protein diets may be the exception Initial weight loss predicts ultimate success Lifestyle interventions with strong behavioral components can be successful Adherence to a diet, not diet macronutrients, is a strong determinant of success 2013 AHA/ACC/TOS Obesity Guidelines recommend any evidence based diet (high carb, low fiber, high fat, etc.) 47