Which Weigh to Go?

Behavioral and Dietary Strategies for Weight Management

March 7, 2013

Presenter: Gary Foster, PhD – Professor of Medicine and Public Health Director of the Center for Obesity Research and Education Temple University 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.

Original recording of the March 7, 2013 webinar and PDF download of presentation available at:

www.ConAgraFoodsScienceInstitute.com

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 2

Prevalence of Overweight and Obesity Among US Adults

- Overweight (BMI ≥25) - Obesity (BMI ≥ 30)

70 60 50 40 30 20 10 0 19 60 -1 96 2 19 71 -1 97 4 19 76 -1 98 0 19 88 -1 99 4/ 91 19 99 -2 00 0 20 01 -2 00 2 NHANES Years 20 02 -2 00 4 20 07 -2 00 8

Flegal, K et al. JAMA, 2002; Hedley, AA et al. JAMA, 2004;Ogden et al JAMA,2006, Flegal et al. JAMA, 2010

Behavioral Factors

•Dietary intake •Physical activity

Portion Sizes

20 18 16 14 12 10 8 1977-78 1989-91 1994-98 6 4 2 0 Sa lty Sn ac ks D es se rts So ft D rin ks Fru it D rin ks Fre nc h Fri es H am bu rg C ers he es eb urg ers Pi zz M a ex ic an F oo d

Nielsen SJ, Popkin BM. JAMA 2003

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. 2005.

Self monitoring in weight loss: a systematic review

Dietary Intake 15 studies found a significant association between dietary self monitoring 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.

Lifestyle Modification for Weight Control

• Reduce energy intake by 500-1000 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

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

Meal Replacements Enhance Initial and Long-term Weight Loss

0 Phase 1* CF 5 10 MR-2 Phase 2 MR-1 15 0 2 4 6 8 10 12 *

1200 –1500 kcal/d diet prescription.

Time (mo)

CF=conventional foods.

MR-2=replacements for 2 meals, 2 snacks daily.

MR-1=replacements for 1 meal, 1 snack daily.

18 24 30 36 45 51 Ditschuneit et al. ,Am J Clin Nutr, 1999 Fletcher-Mors et al., Obes Res, 2000

Meta-Analysis of Partial Meal Replacements (PMR) vs. Reduced Calorie Diets (RCD)

Mean Weight Losses for Completers 4 2 0 -2 -4 -6 -8 -10 -4 *p<.001

-6.5

3 months *p<.001

-4.4

-7 12 months RCD PMR Heymsfeld et al. IJO, 2003

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

Changes in Weight and Hemoglobin A 1c Individuals with type 2 diabetes in Obese 100 Participants (59 women, 41 men) 55.6 ± 10.6 years old 35.8 ± 5.3 kg/m 2 BMI 7.7 ± 1.3% A1c 36% White 59% African American 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

-7 -8 -5 -6 -3 -4 -1 -2 0

*

Weight Loss (kg)

* p<0.0001 **p<0.05

Results

*

BMI (kg/m2)

*

Waist circumference (cm)

**

HbA1c (%) PCD DSME

Foster et al. Nutr Diab, 2013.

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