Clinical Update: Popular diets

Transcription

1 Clinical Update: Popular diets Scott D. Isaacs, MD, FACP, FACE Adjunct Instructor of Medicine, Emory University School of Medicine Medical Director, Atlanta Endocrine Associates Member, AACE Board of Directors

2 Objectives Compare popular weight loss diets with different compositions of macronutrients. Discuss health benefits of diets other than weight loss. Discuss weight loss maintenance.

3 Weight Loss Diets Low-calorie versions of healthy diets Plant-based DASH Mediterranean Low-fat diets Low-carbohydrate diets Very-low-calorie diet (VLCD) Intermittent fasting

4 What Diet is Best? Atkins Vegetarian South Beach Keto Eat Right for Type Pritikin Paleo Mediterranean Macro Ornish DASH Beverly Hills Diet Vegan Volumetrics Rice Diet Simmons LEARN Program Whole-30 Zone Protein Power Sugar Busters Low-GI Low-Carb Gluten-free

5 Responses To Four Popular Diets Courtesy of Scott Kahan, M.D.

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7 Plant-based diets Emphasis on plant-based foods Vegetarian Vegan Mediterranean DASH Combination diets Health benefits 20-25% CVD risk 20-25% Diabetes risk Weight loss comparable to other LCD Harland, Nutrition Bulletin, 2016, Bray, Endocrine Reviews, 2018, 39(2):1-54.

8 Dietary Approaches to Stop Hypertension Vegetables, fruits, and whole grains Low-fat dairy products Fish, poultry, beans Nuts and vegetable oils Limit foods high in saturated fat Limit sugar-sweetened beverages and sweets

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10 DASH Trial: BP and LDL-C DASH-Sodium Trial: DASH Trials DASH + sodium gives greater health benefits than DASH alone DASH-PREMIER Trial: Weight loss and BP

11 Mediterranean Diet High consumption of olive oil High intake of vegetables and fruits and legumes. Non-refined carbohydrates Fish, 3-4 times per week Milk, cheese and yogurt 3-4 eggs per week Moderate consumption of natural meats Nuts as snacks Bray, Endocrine Reviews, 2018, 39(2):1-54.

12 Mediterranean Diet Body fat Waist circumference Diabetes risk CVD risk Bray, Endocrine Reviews, 2018, 39(2):1-54.

13 <30% fat Low-fat diets 33 g fat for every 1000 calories in the diet Healthy carbohydrates (fruits, vegetables, whole grains) Low-fat dairy Avoid processed carbohydrates and sugar. Lessons from the 1990s: calories still matter.

14 Low-carbohydrate diets Low-carb: grams of carbohydrate Very low-carb: < 60 grams of carbohydrate More effective for short-term weight loss but not long-term weight loss Carbohydrate restriction leads to glycogen mobilization and ketosis Rapid weight loss occurs due to glycogen breakdown and fluid loss (not fat loss)

15 Ketogenic Diets Carbohydrate restriction (<20g/d or <5%) Ketosis may appetite and faster weight loss. β-hydroxybutyrate infusions food intake. 1 Ketone drink appetite ratings vs. dextrose. 2 Comparable hunger with or without ketosis. 3 No difference in weight loss at 1 and 5 yrs. 4 1 Hauner. Ann Nutr Metab. 2009;54: Rosen. Am J Clin Nutr. 1985;42: Stubbs. Obesity. 2018;26: Tsai. Obesity 2006; 14:1283.

16 Mixed effect of ketones on appetite signals Ketogenic diet β-hydroxybutyrate Orexigenic GLP-1 PYY GABA Adiponectin Anorexigenic Ghrelin NPY CCK AgRP FFA Paoli, Obesity. 2018;26: Stubbs. Obesity. 2018;26:

17 Side effects of ketogenic diets Constipation Headache Halitosis Muscle cramps Diarrhea General weakness

18 Very Low Calorie Diet (VLCD) <800 kcal/d or <50% REE Meal replacements Behavioral support Rapid weight loss Supplement vitamins and minerals, potassium Medical supervision Bray, et al. Endocrine Reviews 2018;39: National Heart Lung and Blood Institute Obes Res. 1998:6:51-209S SCOOP-VLCD Working Group

19 Protein-Sparing Modified Fast VLCD with regular food Comparable short-term weight loss More difficult to adhere to for longer periods Lean meat, fish, fowl Supplement vitamins and minerals, potassium

20 Meal Replacements A meal replacement is a calorie-controlled drink, bar, soup, etc. intended as a substitute for a standard meal, with controlled quantities of calories and nutrients.

21 Meal Replacements Consistent calorie restriction Structured eating pattern, easier to comply Eliminates meal planning, minimal preparation Cost-effective (replaces groceries, restaurants) Improved weight maintenance at 2 years Greater weight loss with MR + dietitian compared to dietitian alone Bray, et al. Endocrine Reviews 2018;39: Ashley. Obesity Res. 2001;9:312S-320S.

22 How do meal replacements induce greater weight loss? Patients with obesity can underestimate caloric intake by 40-50% Controlled portion sizes Low calorie filling foods Decrease in variety Simplify food choices Functional MRI: calming effect on appetite centers. Bray, et al. Endocrine Reviews 2018;39: 1 54.

23 Intermittent Fasting Alternate day fasting vs. meal timing Works for some people, not for others 75% REE on feast days, 25% REE on fast days 6.5% weight loss in 12 weeks. 1 May increase the risk for diabetes by increasing beta-cell fat. 2 1 Horne. Am J Clin Nutr 2015; 102: Presented at 2018 European Society of Endocrinology Meeting.

24 Intermittent Fasting Gabel, K., et al. Nutrition and Healthy Aging. 2018; 4(4)

25 Initial weight loss predicts ultimate success Wadden, et al. (Look AHEAD Research Group.) Obesity Oct;19(10):

26 1 year % weight change Early weight loss predicts long-term weight loss Month 2 % weight change <3% 3-4% 4-5% 5-6% 6-7% >7% <3% 3-4% 4-5% 5-6% 6-7% >7% Unick. Obesity. 2014;22:

27 What Diet is Best? a) DASH b) Mediterranean c) Plant-based d) Vegan e) Low-fat f) Low-carb g) Ketogenic h) VLCD i) PSMF j) Meal replacements k) Intermittent fasting l) Any healthy lowcalorie diet

28 Macronutrient Content Does Not Influence Weight Loss Sacks, et al. NEJM 2009 Feb 26;360(9):

29 POUNDS Lost Study Adequate-protein/low-fat High-protein/low-fat 15% protein, 20% fat, 65% carb 25% protein, 20% fat, 55% carb Adequate-protein/high-fat High-protein/high-fat 15% protein, 40% fat, 45% carb 25% protein, 40% fat, 35% carb Bray, Endocr Rev. 2018;39(2): doi: /er

30 Response to Diet is Adherence-Dependent Dansinger et al. JAMA 2007.

31 Health benefits other than weight loss Mediterranean diet Diabetes and CVD DASH diet BP and LDL-C Plant based diets Diabetes and CVD

32 Nutrition For Weight Loss Recommendations Jensen M, et al. Circulation Garvey T, et al. Endocr Pract

33 Portion Control Portion sizes parallel obesity rates People given larger portions of high-energy density foods consume calories Urging people to eat less or just push away from the table does not work More effective to low-energy density foods (Eat more low-calorie foods) Rolls. Int J of Obesity, 2014, 38,

34 Losing it is hard, keeping it off is harder

35 Mechanisms for weight regain Decreased metabolism Increased preference for high calorie foods Decreased satiety hormones (leptin, PYY, GLP-1, etc.) Increased ghrelin Behavioral fatigue Obesogenic environment Smith. Health Psychol. 1991;10: Sumithran. New Engl J Med 2011; 365:

36 Behavioral modification Setting realistic goals Self-monitoring (food diaries, activity records) Stimulus control Eating style Meal planning Social support Cognitive restructuring Problem-solving

37 Weight (kg) Benefits of Ongoing Behavioral Support Practice Opportunities for Weight Reduction (POWER) Trial (N=415) Self-directed weight loss In-person support Telephone/Web-based support Months No. patients Appel LJ, et al. N Engl J Med. 2011;365:

38 Conclusions Individual results to diets are highly variable. Adherence to a LCD determines weight loss, not the type of diet. The goal of dietary therapy is to reduce the number of calories consumed. Health benefits of diets other than weight loss. Initial weight loss predicts long-term weight loss.

39 Conclusions Choose a dietary pattern of healthful foods rather than focusing on a specific nutrient. Reduce refined carbohydrates, processed meats, moderate unprocessed red meat. High intakes of vegetables, fruits, nuts, fish, poultry, minimally processed whole grains, legumes, dairy and vegetable oils.

40 Clinical Update: Popular diets Scott D. Isaacs, MD, FACP, FACE