Obesity isn t Simple: Identifying Complex, Evidence-based Strategies to Treat Obesity Seriously

Transcription

1 NUTRI-BITES Webinar Series Obesity isn t Simple: Identifying Complex, Evidence-based Strategies to Treat Obesity Seriously June 21, 2018 Presenters: Andrew W Brown, Ph.D. Assistant Professor Department of Applied Health Sciences Indiana University School of Public Health Bloomington Michelle Bohan Brown, Ph.D., RDN Independent Scientific Consultant Moderator: James M. Rippe, MD Leading cardiologist, Founder and Director; Rippe Lifestyle Institute Approved for 1 CPE (Level 2) by the Commission on Dietetic Registration, credentialing agency for the Academy of Nutrition and Dietetics.

2 Conagra Nutrition Mission We believe that everyone deserves easy access to understandable, credible, and science-based nutrition information.

3 Webinar logistics CEUs a link to obtain your Continuing Education Credit certificate will be available on this webinar s page at and ed to you within 2 business days. A recording of today s webinar and slides as a PDF will be available to download within 2 business days at: The presenter will answer questions at the end of this webinar. Please submit questions by using the Chat dialogue box on your computer screen.

4 Today s Faculty Andrew W Brown, Ph.D. Assistant Professor Department of Applied Health Sciences Indiana University School of Public Health Bloomington Michelle Bohan Brown, Ph.D., RDN Independent Scientific Consultant Moderator: James M. Rippe, MD Leading cardiologist. Founder and Director, Rippe Lifestyle Institute

5 Obesity isn t Simple: Identifying Complex, Evidence-based Strategies to Treat Obesity Seriously NUTRI-BITES Webinar Series Learning Objectives Identify factors that make obesity complex Give examples of simplistic advice and statements that demonstrate the underappreciation of obesity's complexity. Identify evidence-based strategies for obesity, and factors that make them complex.

6 Obesity isn t Simple: Identifying Complex, Evidencebased Strategies to Treat Obesity Seriously 2018, Andrew W Brown, PhD awb1@iu.edu Michelle M. Bohan Brown, PhD, RDN michelle.bohan@gmail.com

7 Acknowledgments Some slides were inspired by or made in collaboration with numerous colleagues. They will be acknowledged throughout verbally, with citations, or on the slides. However, the content reflects our thoughts, and not necessarily these individuals, anyone else, or any organization. Disclosures None relevant for this talk. Collectively, We have received consulting fees, grants (through my institution or colleagues), speaking fees, or travel expenses from academic societies, companies, federal agencies, foundations, and universities for work related to nutrition and obesity. Slides are available upon request:

8 Outline 1.The implied simplicity of obesity 2.Simple ideas that have not worked 3.Treat obesity like the complex condition it is 4.Moving forward

9 The implied simplicity of obesity

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12 Initial BMI Category Men, kg/m 2 Annual Probability of Attaining 5% Reduction in Body Weight Annual Probability of Attaining Normal BMI, Estimate (95% CI) in 12 1 in 210 (197, 225) in 9 1 in 701 (619, 797) in 8 1 in (1023, 1651) in 5 1 in 362 (300, 442) Women, kg/m in 10 1 in 124 (118, 131) in 9 1 in 430 (390, 475) in 7 1 in 677 (599, 769) in 6 1 in 608 (527, 704)

13 E.g., if the individual went from down to 30-34, and subsequently increased to again Data for subsequent changes in BMI category in participants who showed an initial decrease in BMI category for (a) women and (b) men United Kingdom,

14 Simplicity Energy Balance: Is it really this simple? Energy stored = Energy in Energy out

15 Simplicity Energy Balance: Is it really this simple? Energy stored = Energy in Energy out Einstein s razor: Make things as simple as possible but no simpler.

16 Obesity is not simple

17 Comments from Clinicians in Weight Management and Obesity Practice 1. Wish that doctors would refer to a dietitian beyond diabetes and kidney disease. 2. Doctors should not give instructions to lower weight or biomarkers with no advice or referrals or give completely inappropriate advice. 3. My observation is that the biggest disservice comes from ignorance of nutrition and thinking obesity/weight is a simple factor that is easy to control. 4. I know that the MDs and NPs [in the weight loss clinic] would appreciate colleagues not giving inappropriate advice and to refer patients to appropriate providers. 5. Something I noticed of successful doctors [in nutrition and weight] is having a network of other providers - mental health, nutrition, physical therapy, endocrinology etc to refer to when they have patients that extend past their expertise. Knowing what you know is important but knowing what you don't know is even more important.

18 Simple ideas that have not worked The valuable capacity of the human mind to simplify a complex situation becomes dangerous when not controlled in terms of definitely stated criteria. Simon Kuznets, 1934

19 Breakfast eating versus skipping Body weight BMI Lean/FFM Fat % Fat mass WC W:H ratio FMI SAD

20 Fruits and vegetables

21 "Eat your meals off smaller plates and bowls and you'll serve yourself about 10 percent less, which can add up to hundreds of calories less every day."

22 Plate size did not influence energy intake, meal composition, or palatability in normal weight women during a multi-itemed open buffet lunch. Using a smaller dining plate does not suppress food intake from a buffet lunch meal in overweight, unrestrained women The results of the experiment suggest that the plate size had no significant effect on the total energy of the meal. "Eat your meals off smaller plates and bowls and you'll serve yourself about 10 percent less, which can add up to hundreds of calories less every day." Counter to widely held belief, the use of a smaller bowl did not reduce snack food intake. Public health recommendations advising the use of smaller dishware to reduce food consumption are premature, as this strategy may not be effective.

23 Plate size did not influence energy intake, meal composition, or palatability in normal weight women during a multi-itemed open buffet lunch. Using a smaller dining plate does not suppress food intake from a buffet lunch meal in overweight, unrestrained women Cherry picked contrary examples Some examples existed with decreased intake and still more without. "Eat your meals off smaller plates and bowls and you'll serve yourself about 10 percent less, which can add up to hundreds of calories less every day." The results of the experiment suggest that the plate size had no significant effect on the total energy of the meal. But! Counter to widely held belief, the use of a smaller bowl did not reduce snack food intake. Public health recommendations advising the use of smaller dishware to reduce food consumption are premature, as this strategy may not be effective. Where are the RCTs of WEIGHT?

24 Will small sustained changes in energy intake or expenditure produce large, long-term weight changes? year old 165 lb male walking 1 mile/d ~100 kcal/d Weight (lbs) kcal rule Month Weight Loss Predictor:

25 Will small sustained changes in energy intake or expenditure produce large, long-term weight changes? Weight Loss Predictor 35 year old 165 lb male walking 1 mile/d ~100 kcal/d Weight (lbs) In 10 years, he would weigh 61 lbs by the 3500 kcal rule kcal rule Month Weight Loss Predictor:

26 Simple expectations of weight change doi: / The mean difference in energy expenditure between sitting and standing was 0.15 kcal/min By substituting sitting with standing for 6 hours/day, a 65 kg person will expend an additional 54 kcal/day. Assuming no increase in energy intake, this difference in energy expenditure would be translated into the energy content of about 2.5 kg of body fat mass in 1 year.

27 Simple expectations of weight change doi: / The mean difference in energy expenditure between sitting and standing was 0.15 kcal/min By substituting sitting with standing for 6 hours/day, a 65 kg person will expend an additional 54 kcal/day. Assuming no increase in energy intake, this difference in energy expenditure would be translated into the energy content of about 2.5 kg of body fat mass in 1 year.

28 Simple expectations of weight change doi: / The mean difference in energy expenditure between sitting and standing was 0.15 kcal/min By substituting sitting with standing for 6 hours/day, a 65 kg person will expend an additional 54 kcal/day. Assuming no increase in energy intake, this difference in energy expenditure would be translated into the energy content of about 2.5 kg of body fat mass in 1 year.

29 Ignoring complex results for simple messages Effect of Low-Fat vs Low-Carbohydrate Diet on 12-Month Weight Loss in Overweight Adults and the Association With Genotype Pattern or Insulin Secretion The DIETFITS Randomized Clinical Trial 5.3 kg for the low fat diet vs 6.0 kg for the low carbohydrate diet "There was no significant difference in weight change between a healthy low-fat diet vs a healthy low-carbohydrate diet, and neither genotype pattern nor baseline insulin secretion was associated with the dietary effects on weight loss. (emphasis added)

30 Ignoring complex results for simple messages Effect of Low-Fat vs Low-Carbohydrate Diet on 12-Month Weight Loss in Overweight Adults and the Association With Genotype Pattern or Insulin Secretion The DIETFITS Randomized Clinical Trial 5.3 kg for the low fat diet vs 6.0 kg for the low carbohydrate diet "There was no significant difference in weight change between a healthy low-fat diet vs a healthy low-carbohydrate diet, and neither genotype pattern nor baseline insulin secretion was associated with the dietary effects on weight loss. (emphasis added)

31 Treat obesity like the complex condition it is

32 An analogy To extend the obesity oedema analogy, addressing all forms of obesity simply with caloric restriction and exercise ( eat less and move more ) would be akin to addressing all forms of oedema simply with fluid restriction and diuretics.

33 An analogy To extend the obesity oedema analogy, addressing all forms of obesity simply with caloric restriction and exercise ( eat less and move more ) would be akin to addressing all forms of oedema simply with fluid restriction and diuretics. Stated another way, the treatment for edema is straightforward: Drink less, pee more.

34 High-intensity, comprehensive lifestyle intervention N Engl J Med 2017;376: DOI: /NEJMra Adapted from Jensen, et al AHA/ACC/TOS Guidelines

35 Some Medications for Weight Loss Name Orlistat Lorcaserin Liraglutide Phentermine-topiramate Naltrexone-bupropion Action Lipase inhibitor 5HT 2c receptor agonist GLP-1 agonist Norepinephrine-releasing agent; GABA receptor modulation Opioid antagonist; dopamine/norepinephrine reuptake inhibitor Side-effects depend on the drug and the patient. Pregnancy is a contraindication for all of them. Adapted from N Engl J Med 2017;376: DOI: /NEJMra

36 Some Common Surgical Procedures for Weight Loss DeMaria EJ. N Engl J Med 2007;356:

37 Adapted From: Lifestyle intervention Gastric band Comparing Weight Loss at One Year Roux-en-Y Gastric Bypass Vertical sleeve gastrectomy Roux-en-Y Gastric Bypass

38 Moving Forward

39 Moving forward Acknowledge the complexity of the etiology of obesity. First do no harm maintain respect for persons with obesity. Things that do not affect weight might still improve health. For all claims, ask for evidence: Does the recommendation work? If so, in the real world, or in laboratory settings? For whom? For weight loss, preventing weight gain, or helping maintain weight loss? Action can still be taken with weak or no evidence, but it should be done so transparently.

40 Some Resources obesityandenergetics.org obesity.org nutrition.org

41 Obesity isn t Simple: Identifying Complex, Evidencebased Strategies to Treat Obesity Seriously 2018, Andrew W Brown, PhD awb1@iu.edu Michelle M. Bohan Brown, PhD, RDN michelle.bohan@gmail.com

42 Questions?

43 Obesity isn t Simple: Identifying Complex, Evidence-based Strategies to Treat Obesity Seriously NUTRI-BITES Webinar Series Based on this webinar the participant should be able to: Identify factors that make obesity complex. Give examples of simplistic advice and statements that demonstrate the underappreciation of obesity's complexity. Identify evidence-based strategies for obesity, and factors that make them complex.

44 Conagra Nutrition Nutri-Bites Webinar details A link to obtain your Continuing Education Credit certificate will be available on our website and ed within 2 business days Today s webinar will be available to download within 2 business days at: For CPE information: acontinelli@rippelifestyle.com Recent CEU webinars archived at the Conagra Nutrition website: What s New in Obesity Treatment Exploring the Evidence on Dietary Patterns: The Interplay of What We Eat and Health The Academy of Nutrition and Dietetics Evidence Analysis Library: Leveraging This Resource to Maximize Your Efficacy Mediterranean Diet Pattern and Health

45 Next Conagra Nutrition Nutri-Bites Webinars Does Tomato or Lycopene Intake Reduce the Risk of Prostate Cancer? John W. Erdman, PhD Professor Emeritus University of Illinois September 20, pm EDT/1-2pm CDT

46 How are we doing? Stay on the line for a brief survey about today s Conagra Nutrition Nutri-Bites webinar: Obesity isn t Simple: Identifying Complex, Evidence-based Strategies to Treat Obesity Seriously Thank you!