Which Weigh to Go? Behavior and Dietary Strategies for Weight Management March 7, 2013

Transcription

1 Which Weigh to Go? Behavior and Dietary Strategies for Weight Management March 7, 2013 Presenter: Gary D. Foster, PhD Temple University School of Medicine Director, Center for Obesity Research and Education Laura H. Carnell Professor of Medicine, Public Health, and Psychology 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 and the American Culinary Federation.

2 Webinar logistics Continuing Education Credit certificates will be ed as a PDF by March 21st. A recording of today s webinar and slides will be available to download as a PDF within 2 days at: A summary PowerPoint of this presentation will be available to download within 2 days at ww.conagrafoodsscienceinstitute.com The presenters will answer questions at the end of this webinar. Please submit questions by using the Chat dialogue box on your computer screen.

3 ConAgra Foods Science Institute With a mission of: Promoting dietary and related choices affecting wellness by linking evidence-based understanding with practice

4 Today s Faculty Gary D. Foster, PhD Temple University School of Medicine Director, Center for Obesity Research and Education Laura H. Carnell Professor of Medicine, Public Health, and Psychology Moderator: James M. Rippe, MD Leading cardiologist, Founder and Director, Rippe Lifestyle Institute

5 Learning Objectives NUTRI-BITES Webinar Series This webinar will: Evaluate the evidence of diet approaches to weight management Discuss the relationships between portion control and calorie balance Identify evidence-based portion control strategies as part of a weight management program 6

6 Which Weigh to Go? Behavior and Dietary Strategies for Weight Management Gary D. Foster, Ph.D. Laura H. Carnell Professor of Medicine, Public Health, and Psychology Director, Center for Obesity Research and Education Temple University

7 Overview 1. Overview of behavioral treatment 2. Benefits of portion control 3. Role of macronutrients 4. Q & A

8 Prevalence of Overweight and Obesity Among US Adults -- Overweight (BMI 25) -- Obesity (BMI 30) Prevalence (%) / NHANES Years Flegal, K et al. JAMA, 2002; Hedley, AA et al. JAMA, 2004;Ogden et al JAMA,2006, Flegal et al. JAMA, 2010

9 Medical Complications of Obesity Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Gall bladder disease Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Osteoarthritis Skin Gout Idiopathic intracranial hypertension Stroke Cataracts Coronary heart disease Diabetes Dyslipidemia Hypertension Severe pancreatitis Cancer breast, uterus, cervix colon, esophagus, pancr eas kidney, prostate Phlebitis venous stasis

10 Behavioral Factors Dietary intake Physical activity

11 Portion Sizes Portion size, ounces Salty Snacks Desserts Soft Drinks Fruit Drinks French Fries Hamburgers heeseburgers Pizza Mexican Food Nielsen SJ, Popkin BM. JAMA 2003

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16 Environmental Factors Marketing Bigger packages, multiple unit pricing, quantity limits Bigger equals cheaper Supersize 22 oz soda for $2.50 versus 44 oz for $3.00 All-you-can-eat buffets

17 Behavioral Treatment of Obesity Consists of a set of principles and techniques to modify eating and activity habits Treatment is designed to increase skills not insight Treatment recognizes non-behavioral causes of obesity Foster, Makris, Bailer. AJCN

18 Antecedent Behavior Consequence

19 Brownell KD. The LEARN Program for Weight Control. 7th ed. American Health Publishing Co; A Sample Behavior Chain Buy Cookies Leave Cookies on Counter Home on Saturday Afternoon Tired and Bored Eat While Watching TV Take Cookies to TV Room Go to Kitchen Urge to Eat Eat Rapidly Until Full Feel Guilty/ Like a Failure Restraint Weakens Further More Eating

20 Self-Monitoring Food Intake Types of foods Portion sizes Calories (reduce by 500 kcal/d) Times, places, and activities Thoughts and moods Brownell: Learn Program for Weight Control, 1998

21 Antecedents Time Places Activities Thoughts Emotions

22 Self monitoring in weight loss: a systematic review Dietary Intake 15 studies found a significant association between dietary selfmonitoring and weight loss Participants with the most complete food records lost significantly more weight than those who had less complete records Physical Activity 5 studies discussed the use of records for tracking exercise behaviors Consistent self monitors of exercise achieved significantly greater weight loss and experienced fewer difficulties with exercise, and exercised more often Weight Weight self-monitoring increases participants awareness of weight and related energy intake & expenditure More frequent weighing is associated with greater weight loss Burke LE et al. JADA 2011.

23 Lifestyle Modification for Weight Control Reduce energy intake by kcal/day (by reducing portion size, fat, and sugar). Exercise > 180 min/week. Record food intake, physical activity, and weight. Set realistic goals for weight loss (5%-10% loss to improve health and well being). Diabetes Prevention Research Group, NEJM, 2002

24 Diabetes Prevention Program Change in Weight (kg) Lifestyle: Months 1-6, 16 individual sessions with a RD Placebo Metformin Lifestyle Year Diabetes Prevention Research Group, NEJM, 2002

25 Diabetes Prevention Program 40 Placebo Cumulative Incidence of Diabetes (%) Metformin Lifestyle Year Diabetes Prevention Research Group, NEJM, 2002

26 Portion-Controlled Meals Provides fixed-portion and calorie amounts Counters underestimation of portion and calories Reduces choices and contact with problem foods Are convenient to use Satisfies appetite (monotony and sensory specific satiety) Facilitates dietary adherence

27 Meal Replacements Enhance Initial and Long-term Weight Loss Phase 1* Phase 2 Percentage Weight Loss CF MR * kcal/d diet prescription. CF=conventional foods. MR-2=replacements for 2 meals, 2 snacks daily. MR-1=replacements for 1 meal, 1 snack daily. Time (mo) MR-1 Ditschuneit et al.,am J Clin Nutr, 1999 Fletcher-Mors et al., Obes Res, 2000

28 Meta-Analysis of Partial Meal Replacements (PMR) vs. Reduced Calorie Diets (RCD) Mean Weight Losses for Completers Weight Loss (in kg) *p<.001 *p< months 12 months RCD PMR Heymsfeld et al. IJO, 2003

29 Look AHEAD Study Design SAMPLE 5145 obese participants with type 2 diabetes RANDOMIZATION Usual care (Diabetes Support and Education Group) Usual care + Lifestyle Intervention STUDY DURATION 12 years, with 4 years of intensive intervention PRIMARY OUTCOME Cardiovascular deaths (fatal MI and stroke) Nonfatal MI Nonfatal stroke The Look AHEAD Research Group, Controlled Clinical Trials, 2003

30 Look AHEAD Lifestyle Intervention Using DPP protocol with modifications: Group treatment Meal replacements Lifestyle activity Toolbox that includes weight loss medication

31 Look AHEAD: Intensive Lifestyle Intervention (ILI): Months 1-48 Months 1-6 Contact 4 times/month 3 groups sessions & 1 individual session Months 7-12 Contact 3 times/month 2 group sessions & 1 individual session Months Contact 2 times/month 1 individual session & 1 telephone call or contact & variety of ancillary group classes Personal weight loss goal= 10% reduction in initial weight Study weight loss goal 7% The Look AHEAD Research Group, Arch Intern Med, 2010

32 Diabetes Support and Education (DSE): Months group sessions/year Promote retention Health education topics Diet Exercise Social support The Look AHEAD Research Group, Arch Intern Med, 2010

33 % Weight Loss at 1-Year 0 Lifestyle DSE % Weight Change p < % %

34 Percentage change in weight, baseline to 4y 0-1 % Reduction in inital weight Lifestyle DSE Year Averaged across 4 years, Lifestyle participants had a greater percentage of weight loss than DSE participants (-6.15% vs -0.88%; p<.001) The Look AHEAD Research Group, Arch Intern Med, 2010

35 Changes in Weight and Hemoglobin A 1c in Obese Individuals with type 2 diabetes 100 Participants (59 women, 41 men) 55.6 ± 10.6 years old 36% White 35.8 ± 5.3 kg/m 2 BMI 59% African American 7.7 ± 1.3% A1c Participants were randomly assigned to either a 6 month, 9- session: Lifestyle intervention that included a portion-controlled diet (PCD): Nutrisystem D Diabetes self-management (DSME) Primary outcome was change in weight, secondary outcome was change in HbA1c Foster et al. Nutr Diab, 2013

36 PCD (n=50) and DSME (n=50) Group behavioral sessions 8-12 people per group 90 minute sessions at weeks 0, 1, 2, 4, 8, 12, 16, 20, 24 Energy intake goals 1250 kcal/d for women 1550 kcal/d for men Calorie counting guides Physical activity goal Progress to 180 min/wk of brisk walking Blood glucose monitoring goal Monitor blood glucose throughout the study Foster et al. Nutr Diab, 2013

37 Results * Weight Loss (kg) * BMI (kg/m2) * Waist circumference ** (cm) HbA1c (%) PCD DSME * p< **p<0.05 Foster et al. Nutr Diab, 2013.

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39 Relationship between portion control behavior and other weight control behaviors Self-monitoring Greater ease Reducing energy intake Reduce portion Reduce frequency Consume an alternative Stimulus control Limits environmental cues

40 The Dieter s Dilemma

41 Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates Sample description (N=811) 515 female, 296 male Age 51.9 ± 9 years old BMI 33 ± 4.0kg/m 2 Weight 93 ±16 kg All participants were offered group and individual instructional sessions for 2 years. Sacks et al, NEJM, 2008

42 POUNDS LOST: Diets Diet Protein Fat Carbohydrate Orange 25% 40% 35% Green 15% 40% 45% Pink 25% 20% 55% Blue 15% 20% 65% Sacks et al, NEJM, 2008

43 POUNDS LOST: Body weight Over 2 Yrs, ITT Diet Composition Carbohydrate/Protein/Fa t (% energy) 65/15/20 55/25/20 45/15/40 35/25/ Months Sacks et al, NEJM, 2008

44 Calories or Carbs? N: 43 Weeks: 6 (inpatient) Diets: Isocaloric (1000 kcal/d) (15% vs. 45% CHO) Weight Loss: kg kg Golay, Int J Obes, 1996

45 Comparison of Low-Carbohydrate and Low-Fat Diets for Obesity: A Two-Year, Multi-Center Randomized Trial 317 Participants (208 women, 99 men) 45.5 ± 9.7 years old 36.1 ± 3.5kg/m 2 BMI 74.9% European American Participants were randomly assigned to either: Low-carbohydrate diet: Limited carbohydrate intake with unrestricted consumption of fat and protein. Low-fat diet: Limiting energy intake to 1200 to 1500 kcal/d for women and 1500 to 1800 kcal/d for men, with approximately 55 percent of calories from carbohydrate, 30 percent from fat, and 15 percent from protein. All participants received group behavior treatment for 2 years. Foster et al., Ann Intern Med, 2010

46 Weight Loss 0 Change in Weight (kg) Month -- Low fat -- Low Carbohydrate Foster et al., Ann Intern Med, 2010

47 Lipid Changes Triglycerides 0 VLDL Cholesterol 0 Change in Triglycerides (mg/dl) Change in VLDL Cholesterol (mg/dl) HDL LDL Change in HDL Cholesterol (mg/dl) 5 0 Change in LDL Cholesterol (mg/dl) Low fat -- Low Carbohydrate Foster et al., Ann Intern Med, 2010

48 When it comes to weight loss CALORIES COUNT!

49 Summary 1. Behavioral strategies, including self monitoring, facilitate greater weight loss 2. Portion control strategies produce greater weight loss than conventional foods 3. Energy level is more important than the macronutrient mix for weight loss

50 Clinical Implications 1.Track intake, activity, and weight 2.Encourage portion control strategies (frozen entrées, bars, shakes, meal replacements) 3.Focus on calories 4.Keep it simple

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52 Questions?

53 Behavior and Dietary Strategies for Weight Management NUTRI-BITES Webinar Series This webinar covered: Evidence of diet approaches to weight management Relationship between portion control and calorie balance Identified evidence-based portion control strategies as part of a weight management program 54

54 Nutri-Bites Webinar details For CPE information: Continuing Education Credit certificates will be ed as a PDF by March 21st. Today s webinar will be available to download as a PDF within 2 days at: A slide summary PowerPoint of this presentation will be available to download within 2 days at:

55 Next Nutri-Bites Webinar Fresh Look at Cool Foods: Exploring Myths and Trends of Frozen Foods Phil Lempert - Consumer Trend expert Kristin Reimers, PhD, RD Manager of Nutrition at ConAgra Foods Date: May 2, pm EDT/1-2 pm CDT

56 How are we doing? Stay on the line for a brief survey about this Nutri-Bites webinar: Which Weigh to Go? Behavior and Dietary Strategies for Weight Management Thank you!

57 Celebrate National Nutrition Month! Congratulations RDs! March 13 is your day!