Dietary Composition for Weight Loss and Weight Loss Maintenance

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1 Dietary Composition for Weight Loss and Weight Loss Maintenance Bridget M. Hron, MD Instructor in Pediatrics, Harvard Medical School Staff Physician in Gastroenterology & Nutrition and New Balance Foundation Obesity Prevention Center Boston Children s Hospital

2 From snowy Boston to sunny Phoenix

3 What should I eat?

4 Outline Review general consensus on weight loss and weight loss maintenance Discuss two key areas of debate regarding effects of dietary macronutrient composition Address pediatric literature related to dietary composition Translate these findings into clinical practice

5 General consensus American diet quality is poor, and contributes to burden of obesity and related diseases

6

7 Key line from the Executive Summary The overall body of evidence examined by the 2015 DGAC identifies that a healthy dietary pattern is higher in vegetables, fruits, whole grains, low or non fat dairy, seafood, legumes and nuts; moderate in alcohol consumption (among adults); lower in red and processed meat; and low in sugar sweetened foods and drinks and refined grains.

8 General consensus American diet quality is poor, and contributes to burden of obesity and related diseases Hypocaloric diets are equally efficacious at achieving weight loss

9 High fat Very low carbohydrate Low glycemic load Portion control & calorie counting Low fat High carbohydrate Dansinger et al. JAMA 2005

10 Dansinger et al. JAMA 2005

11 General consensus American diet quality is poor, and contributes to burden of obesity and related diseases Hypocaloric diets are equally efficacious at achieving weight loss Adherence is important to treatment success

12 Dansinger et al. JAMA 2005

13 General consensus American diet quality is poor, and contributes to burden of obesity and related diseases Hypocaloric diets are equally efficacious at achieving weight loss Adherence is critical for weight loss success Weight loss improves cardiovascular disease markers

14 The degree of improvement in cardiovascular risk parameters correlates with change in body weight Dansinger et al. JAMA 2005

15 General consensus American diet quality is poor, and contributes to burden of obesity and related diseases Hypocaloric diets are equally efficacious at achieving weight loss Adherence is critical for weight loss success Weight loss improves cardiovascular disease markers Long term weight loss strategies are generally ineffective

16 Few adults report long term weight loss success According to data from NHANES ( ), only 1 in 6 adults who were obese or overweight report ever having maintained weight loss of at least 10% for 1 year Why might this be the case? Kraschnewski et al. Int J Obes (Lond) 2010

17 The physiologic effects of weight loss are designed to preserve the biologic weight set point

18 Resting energy expenditure decreases with weight loss Leibel RL et al. N Engl J Med 1995

19 Hunger increases with weight loss Sumithran et al. NEJM 2011

20 Adipokines and enteric hormones may be responsible for effect on appetite Leptin falls with weight loss in association with loss of fat mass Administration of satiety hormone leptin to fasting women blunts sensation of hunger Ghrelin increases with weight loss Sumithran et al. NEJM 2011 Schurgin et al. JCEM 2004

21 In a low energy state, catabolism is favored over anabolism Reproductive function decreases Thyroid axis is suppressed Growth hormone increases while IGF 1 decreases, suggesting pattern of GH resistance Teliologically, these adaptations function to preserve body weight and avoid energyexpensive endeavors such as growth and reproduction Schurgin et al. JCEM 2004 Ho et al. JCI 1998

22 Outline Review general consensus on weight loss and weight loss maintenance Discuss two key areas of debate regarding effects of dietary macronutrient composition Address pediatric literature related to dietary composition Translate these findings into clinical practice

23 Where controversy arises Does dietary macronutrient content affect energy expenditure and other weight loss induced changes in metabolism which predispose to weight regain? Does macronutrient content affect weight loss induced improvement in cardiovascular disease risk factors?

24 Jenkins DJ et al. Ludwig DS. JAMA 2002

25 The Glycemic Load Glycemic index (measure of carbohydrate quality) multiplied by amount of carbohydrate consumed Ludwig DS. JAMA 2002

26 Glycemic load of popular diets Diet Carbohydrate Amount Glycemic Index Glycemic Load Low-fat High (up to 60% of energy) High High Low-glycemic index Moderate (40% of energy) Low Moderate Very low-carbohydrate Very low ( 10% of energy) Irrelevant Low

27 The physiology of the glycemic index Ludwig DS. JAMA 2002

28 Plausible physiologic consequence of high GI diet Ludwig DS. JAMA 2002

29 Popular diets study design Low Fat 60% CHO 20% Fat 20% Protein Low Glycemic Index 40% CHO 40% Fat 20% Protein Very Low CHO 10% CHO 60% Fat 30% Protein Ebbeling et al. JAMA 2012

30 Sample breakfast Low-Fat Glycemic Load Low Fat ± 8.6 Low Glycemic Index 51.1 ± 6.3 Very Low Carbohydrate 3.9 ± 2.2 Low-Glycemic Index Very-Low-Carbohydrate

31 Popular diets outcome measures Primary outcome: REE Secondary outcomes: Energy metabolism: TEE Catabolic/anabolic hormones: thyroid function & cortisol Metabolic parameters: insulin sensitivity Ebbeling et al. JAMA 2012

32 REE & TEE decreased to the least extent with very low carbohydrate diet REE kcal/day P=0.03 (LF=LGI=VLC) P=0.009 (LF LGI VLC) BL LF LGI VLC Ebbeling et al. JAMA 2012

33 Effects on EE are not mediated through thyroid axis TSH P=0.04 Total T3 P= P= P= IU/mL 1.0 ng/dl BL LF LGI VLC 80 BL LF LGI VLC Ebbeling et al. JAMA 2012

34 Urinary cortisol increased in response to very low carbohydrate diet 120 P= P=0.001 g/day BL LF LGI VLC Ebbeling et al. JAMA 2012

35 Dietary composition affects weightloss induced changes in metabolism The low carbohydrate diet, compared to low fat diet, had the least impact on weight loss induced changes in resting and total energy expenditure However, this was associated with increased urinary serum cortisol

36 Where controversy arises Does dietary macronutrient content affect energy expenditure and other risk factors which predispose to weight regain? Does macronutrient content affect weight loss induced improvement in cardiovascular disease risk factors?

37 Dietary composition in weightmaintenance state The Omni Heart study demonstrated that replacement of saturated fat with unsaturated fat or protein compared to carbohydrate improves blood pressure, total cholesterol, triglyceride and LDL levels; HDL variable Recent data from the Omni Carb study suggest this effect in the context of an overall healthful diet may be driven by carbohydrate quantity, less so glycemic index Appel et al. JAMA 2005 Sacks et al. JAMA 2014

38 mg/dl HDL and triglycerides improved the most in response to VLC diet HDL Cholesterol P <0.001 P<0.001 BL LF LGI VLC Triglycerides P <0.001 P<0.001 BL LF LGI VLC Ebbeling et al. JAMA 2012

39 However, non HDL cholesterol improved in response to low fat diet Non HDL Cholesterol P < P< BL LF LGI VLC Ebbeling et al. JAMA 2012

40 No significant effects of dietary composition were observed on blood pressure Systolic: P=0.34 Diastolic: P=0.35 mm Hg BL LF LGI VLC Ebbeling et al. JAMA 2012

41 Insulin sensitivity improves in conjunction with decreasing carbohydrate intake 2 Hepatic P= Peripheral P= P= P= BL LF LGI VLC 0.0 BL LF LGI VLC Ebbeling et al. JAMA 2012

42 However Trend in CRP levels showed smallest improvement in very low carbohydrate diet

43 Dietary composition does affect cardiovascular risk parameters The pattern of improvement in insulin sensitivity and overall cholesterol profile during weight loss maintenance favors low carbohydrate diets, with exception of cortisol levels and possibly CRP Whether there is additional benefit to limiting glycemic load within a low carbohydrate diet is debatable

44 Outline Review general consensus on weight loss and weight loss maintenance Discuss two key areas of debate regarding effects of dietary macronutrient composition Address pediatric literature related to dietary composition Translate these findings into clinical practice

45 Early data suggested that low glycemic load diets may improve body composition in children Ebbeling et al. Arch Pediatr Adolesc Med. 2003

46 Body composition improved similarly with weight loss without effect of dietary composition Kirk et al. J Pediatr 2011

47 However, lower compliance was observed on the low carbohydrate diet Kirk et al. J Pediatr 2011

48 There was no consistent pattern on the effects of dietary composition on cardiovascular risk parameters in children In Kirk et al. study: Low carbohydrate: Improved triglycerides & HDL Reduced glycemic load: Improved insulin, LDL levels Portion control: Improved insulin & HDL levels In Ebbeling et al. study: Improved pattern of insulin resistance with reduced glycemic load

49 Summarizing the pediatric literature Dietary macronutrient composition does not have a consistent effect on body weight regulation or cardiovascular risk parameters in the context of reduced calorie diets However, there is very little data in children using a feeding protocol, which may have better treatment fidelity, and few data that address underlying physiology

50 Outline Review general consensus on weight loss and weight loss maintenance Discuss two key areas of debate regarding effects of dietary macronutrient composition Address pediatric literature related to dietary composition Translate these findings into clinical practice Ebbeling et al. JAMA 2012

51 General consensus American diet quality is poor, and contributes to burden of obesity and related diseases Hypocaloric diets are equally efficacious at achieving weight loss Adherence is critical for weight loss success

52 A debatable addendum to the consensus statement: Weight loss improves cardiovascular disease markers The overall pattern of improvement favors low carbohydrate diets, though HDL response is not well established Long term weight loss strategies are generally ineffective Low carbohydrate diets favor metabolic profiles that are less likely to result in weight regain, with the exception of increased cortisol excretion

53 What do I tell my pediatric patients? Eat less! Decreasing calorie consumption, however it s done, can lead to weight loss Stick to it! The most important predictor of weight loss success is adherence to diet Choose whole foods! Choose a diet rich in fruits and vegetables with low glycemic index sources of carbohydrate, avoiding sugar sweetened foods and refined grains

54 Exciting directions for future research Physiologic mechanisms linking macronutrient composition to whole organism metabolism, such as adipokine levels or intestinal microbiome Individual phenotypes that promote weight regain, and individualized treatment strategies to minimize this risk Sustainable, effective strategies to promote adherence to weight loss and weight loss maintenance both on individual and national scale Specifically address these concepts in the pediatric population

55 Acknowledgements Cara B. Ebbeling, PhD David S. Ludwig, MD, PhD

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