Weight Management: Popular Approaches

Formula Diets and Meal Replacements• Meal formats and nutritional profiles varyMeal formats and nutritional profiles vary• Total calories range from 1000-1600 kcals Total calories range from 1000-1600 kcals

day with meal replacement drinks or bars day with meal replacement drinks or bars replacing two meals during weight loss or replacing two meals during weight loss or one meal for weight maintenanceone meal for weight maintenance

Formula Diets and Meal Replacements• There is evidence There is evidence

that meal that meal replacements can replacements can be as effective as be as effective as standard low-standard low-calorie diets in calorie diets in promoting weight promoting weight lossloss

Evaluation of Major Commercial Weight Loss Programs

• Reviewed research regarding the efficacy of Reviewed research regarding the efficacy of commercial weight loss programs including commercial weight loss programs including Weight Watchers, Jenny Craig, LA Weight Weight Watchers, Jenny Craig, LA Weight Loss, HMR, OPTIFAST, commercial Loss, HMR, OPTIFAST, commercial Internet programs (e-diets.com); Overeaters Internet programs (e-diets.com); Overeaters Anonymous and Take Off Pounds SensiblyAnonymous and Take Off Pounds Sensibly

(Tsai and Wadden, Ann Int Med 2005; 142:56-66)(Tsai and Wadden, Ann Int Med 2005; 142:56-66)

Evaluation of Major Commercial Weight Loss Programs

• Weight Watchers had the strongest studies Weight Watchers had the strongest studies to support itto support it• Best study: participants lost 5% of their Best study: participants lost 5% of their

initial body weight (about 10 pounds) and initial body weight (about 10 pounds) and kept off 3% (about 5 pounds) at 2 yearskept off 3% (about 5 pounds) at 2 years

• No published high-quality studies of No published high-quality studies of Jenny Craig or LA Weight LossJenny Craig or LA Weight Loss

(Tsai and Wadden, Ann Int Med 2005; 142:56-66)(Tsai and Wadden, Ann Int Med 2005; 142:56-66)

Evaluation of Major Commercial Weight Loss Programs

• Studies of VLCDs were of limited qualityStudies of VLCDs were of limited quality• Patients who stayed on the program lost 15-Patients who stayed on the program lost 15-

20% of initial body weight in 6 months20% of initial body weight in 6 months• Many patients dropped out of these programsMany patients dropped out of these programs• Those who completed the program regained Those who completed the program regained

half of lost weight in 1-2 years after treatmenthalf of lost weight in 1-2 years after treatment• Studies of internet-based programs of limited Studies of internet-based programs of limited

quality and produced minimal weight lossquality and produced minimal weight loss

(Tsai and Wadden, Ann Int Med 2005; 142:56-66)(Tsai and Wadden, Ann Int Med 2005; 142:56-66)

Atkins Diet Premise

• Stabilizes insulin production by limiting Stabilizes insulin production by limiting carb intake. This forces the body from carb intake. This forces the body from glucosis into lipolysis, thus ketones are glucosis into lipolysis, thus ketones are burned as the primary energy source.burned as the primary energy source.

• This results in a metabolic advantage of low This results in a metabolic advantage of low carbohydrate: dieters can lose weight while carbohydrate: dieters can lose weight while eating more calorieseating more calories

Atkins Diet: Induction Phase

• ““Induction Phase”: 2 weeks, 20 g carb/day Induction Phase”: 2 weeks, 20 g carb/day • Eliminate fruit, bread, grains, starchy Eliminate fruit, bread, grains, starchy

vegetables, dairy products except cheese, vegetables, dairy products except cheese, cream, buttercream, butter

• 20 g carb: 3 cups salad greens, or 2 cups salad 20 g carb: 3 cups salad greens, or 2 cups salad plus 2/3 cups cooked vegetables such as plus 2/3 cups cooked vegetables such as asparagus, summer squash, green beansasparagus, summer squash, green beans

Atkins- Sample Menu Phase 1

• B: scrambled eggs and ham, butter, B: scrambled eggs and ham, butter, decaffeinated coffee or teadecaffeinated coffee or tea

• L: Bacon cheeseburger, no bun, small L: Bacon cheeseburger, no bun, small tossed salad, selzer watertossed salad, selzer water

• D: shrimp cocktail with mustard and mayo, D: shrimp cocktail with mustard and mayo, clear consomme, steak, roast, fish or fowl, clear consomme, steak, roast, fish or fowl, tossed salad, diet gelatin with whipped tossed salad, diet gelatin with whipped cream, sf beveragecream, sf beverage

Atkins Phase 2: OWL

• ““Ongoing weight loss phase” or “Owl.” Ongoing weight loss phase” or “Owl.” • Add carbohydrate at a rate of 5 grams a day Add carbohydrate at a rate of 5 grams a day

until weight loss stopsuntil weight loss stops• This is the CCLL: critical carbohydrate level This is the CCLL: critical carbohydrate level

for losingfor losing• May be 45, or 33, or 19 grams/dayMay be 45, or 33, or 19 grams/day• Continue at this level until desired weight is Continue at this level until desired weight is

reachedreached

Atkins: Sample menu OWL

• B: Western omelet, 3 ounces tomato juice, 2 B: Western omelet, 3 ounces tomato juice, 2 carbo grams of bran crispbread, decaf carbo grams of bran crispbread, decaf coffee or teacoffee or tea

• L: Chef’s salad with ham, cheese, chicken L: Chef’s salad with ham, cheese, chicken and egg; zero carbohydrate or oil and and egg; zero carbohydrate or oil and vinegar dressing, iced herbal teavinegar dressing, iced herbal tea

• D: Seafood salad, poached salmon, 2/3 cup D: Seafood salad, poached salmon, 2/3 cup vegetable from permitted list, half cup of vegetable from permitted list, half cup of strawberries in creamstrawberries in cream

South Beach Diet Premise• ““Addiction” to carbs is a psychological need for Addiction” to carbs is a psychological need for

comfort food and is likely a real, physiological comfort food and is likely a real, physiological phenomenonphenomenon

• Eating bad carbs leads to cravings for more which Eating bad carbs leads to cravings for more which is “ultimately responsible for our obesity epidemic”is “ultimately responsible for our obesity epidemic”

• States that Atkins may limit carbs too severely States that Atkins may limit carbs too severely • Stresses glycemic index as the biggest determinant Stresses glycemic index as the biggest determinant

of a food’s potential impact on body weightof a food’s potential impact on body weight

South Beach Diet: Phase 1 (2 weeks)• Carbs limited to low-carb vegetables, salads, 1% Carbs limited to low-carb vegetables, salads, 1%

milk, fat-free buttermilk, nonfat yogurt. milk, fat-free buttermilk, nonfat yogurt. • Proteins: unlimited lean meats, poultry, fish, low fat Proteins: unlimited lean meats, poultry, fish, low fat

cheese, tofu cheese, tofu • Nuts included, but limitedNuts included, but limited• ““Good” fats including olive, canola oilsGood” fats including olive, canola oils• Sugar-free hard candies, diet gelatin, sugar subsSugar-free hard candies, diet gelatin, sugar subs• NO fatty meats, starchy vegetables like corn, NO fatty meats, starchy vegetables like corn,

potatoes, carrots, fruits, grains, alcoholpotatoes, carrots, fruits, grains, alcohol

South Beach: Sample Day Phase 1• B: 6 oz tomato juice, 1/4-1/2 cup liquid egg B: 6 oz tomato juice, 1/4-1/2 cup liquid egg

substitute, decaf coffee or tea, non-fat milk, sugar substitute, decaf coffee or tea, non-fat milk, sugar substitutesubstitute

• snack: 1-2 turkey roll upssnack: 1-2 turkey roll ups• L: SB chopped salad with tuna, sf gelatinL: SB chopped salad with tuna, sf gelatin• snack: celery, 1 wedge Laughing Cow Light Cheesesnack: celery, 1 wedge Laughing Cow Light Cheese• D: baked chix breast, roasted eggplant and peppers, D: baked chix breast, roasted eggplant and peppers,

salad, lo sugar dressingsalad, lo sugar dressing• Dessert: Mocha Ricotta CremeDessert: Mocha Ricotta Creme

South Beach: Sample Day Phase 2

• B: 1 cup blueberries; 1 scrambled egg w/ salsa; B: 1 cup blueberries; 1 scrambled egg w/ salsa; oatmeal mixed with 1 cup nonfat milk, sprinkled with oatmeal mixed with 1 cup nonfat milk, sprinkled with cinnamon and walnuts; coffee or teacinnamon and walnuts; coffee or tea

• Snack: 4 oz non-fat sugar-free yogurtSnack: 4 oz non-fat sugar-free yogurt• L: Tuna salad w/ celery, mayo, tomato, onion in L: Tuna salad w/ celery, mayo, tomato, onion in

whole wheat pitawhole wheat pita• Snack: 1 part-skim mozzarella cheese stickSnack: 1 part-skim mozzarella cheese stick• D: Pan roasted steak and onions, South Beach salad, D: Pan roasted steak and onions, South Beach salad,

steamed broccoli; chocolate-dipped strawberriessteamed broccoli; chocolate-dipped strawberries

South Beach Diet: Phase 2• Reintroduces most fruits, whole grains (sparingly) Reintroduces most fruits, whole grains (sparingly)

including popcorn, legumes such as pinto beans, including popcorn, legumes such as pinto beans, starchy vegetables such as peas, carrots and sweet starchy vegetables such as peas, carrots and sweet potatoes, flavored nonfat yogurt, semisweet or potatoes, flavored nonfat yogurt, semisweet or bittersweet chocolate, winebittersweet chocolate, wine

• Still forbidden: white flour and products made Still forbidden: white flour and products made from it including breads, cookies, pasta; potatoes, from it including breads, cookies, pasta; potatoes, white rice, corn; fruits including bananas, canned white rice, corn; fruits including bananas, canned fruit, pineapple, raisins, watermelonfruit, pineapple, raisins, watermelon

• Dieters stay in this phase until goal weight Dieters stay in this phase until goal weight achievedachieved

South Beach: Sample Day Phase 2

• B: 1 cup blueberries; 1 scrambled egg w/ salsa; B: 1 cup blueberries; 1 scrambled egg w/ salsa; oatmeal mixed with 1 cup nonfat milk, sprinkled with oatmeal mixed with 1 cup nonfat milk, sprinkled with cinnamon and walnuts; coffee or teacinnamon and walnuts; coffee or tea

• Snack: 4 oz non-fat sugar-free yogurtSnack: 4 oz non-fat sugar-free yogurt• L: Tuna salad w/ celery, mayo, tomato, onion in L: Tuna salad w/ celery, mayo, tomato, onion in

whole wheat pitawhole wheat pita• Snack: 1 part-skim mozzarella cheese stickSnack: 1 part-skim mozzarella cheese stick• D: Pan roasted steak and onions, South Beach salad, D: Pan roasted steak and onions, South Beach salad,

steamed broccoli; chocolate-dipped strawberriessteamed broccoli; chocolate-dipped strawberries

South Beach Diet: Phase 3

• Maintenance- no foods are forbiddenMaintenance- no foods are forbidden• Continue to limit high carb, refined or Continue to limit high carb, refined or

heavily processed foods. heavily processed foods. • Return to earlier phase if weight gain occursReturn to earlier phase if weight gain occurs

South Beach vs Atkins Phase 1

Atkins Atkins • Proteins: All meats, poultry, Proteins: All meats, poultry,

fish, shellfish, eggs, cheese are fish, shellfish, eggs, cheese are unlimitedunlimited

• Fats: vegetable oils, butter, Fats: vegetable oils, butter, mayonnaise, heavy cream, mayonnaise, heavy cream, baconbacon

• Vegetables: 3 cups salad or 2 Vegetables: 3 cups salad or 2 cups salad and 2/3 cup low carb cups salad and 2/3 cup low carb vegetablesvegetables

• NO: artificial sweeteners, NO: artificial sweeteners, margarine, fruits, grains, margarine, fruits, grains, breads, starchy vegetables, breads, starchy vegetables, dairy, alcoholdairy, alcohol

South BeachSouth Beach• Proteins: Lean beef, pork, Proteins: Lean beef, pork,

skinless poultry, low fat cheese, skinless poultry, low fat cheese, seafood, eggsseafood, eggs

• Fats: Canola and olive oilFats: Canola and olive oil• Vegetables: salad greens, beans, Vegetables: salad greens, beans,

tomatoes, cabbage, summer tomatoes, cabbage, summer squash, broccoli, all low carb are squash, broccoli, all low carb are unlimitedunlimited

• Dairy: Fat free or 1% milk or Dairy: Fat free or 1% milk or yogurtyogurt

• NO: fatty meat, high fat cheese; NO: fatty meat, high fat cheese; fruits, grains, breads, starchy fruits, grains, breads, starchy vegetables, butter, margarine, vegetables, butter, margarine, alcoholalcohol

High Carbohydrate Low Fat Diets• The Pritikin Weight Loss BreakthroughThe Pritikin Weight Loss Breakthrough• Eat More, Weigh Less (Dean Ornish)Eat More, Weigh Less (Dean Ornish)

High Carb Low Fat Diets

• Rationale: diet is high in bulk and fiber, low Rationale: diet is high in bulk and fiber, low in calorie density producing early satiety in calorie density producing early satiety and weight lossand weight loss

• Description: 50-75% carbohydrate calories, Description: 50-75% carbohydrate calories, relatively less meat, fish, fats and oils, more relatively less meat, fish, fats and oils, more grains, cereals, breads, fruits, vegetablesgrains, cereals, breads, fruits, vegetables

Sample Menu: High Carb Low Fat

• B: 1 cup blueberries; oatmeal mixed with 1 cup B: 1 cup blueberries; oatmeal mixed with 1 cup nonfat milk, sprinkled with cinnamon and nonfat milk, sprinkled with cinnamon and walnuts; coffee or teawalnuts; coffee or tea

• Snack: 4 oz non-fat sugar-free yogurtSnack: 4 oz non-fat sugar-free yogurt• L: Vegetarian vegetable soup, fresh orange, nonfat L: Vegetarian vegetable soup, fresh orange, nonfat

yogurt yogurt • D: Grilled salmon with yogurt-dill sauce, bulgur D: Grilled salmon with yogurt-dill sauce, bulgur

with raisins, steamed broccoli; strawberries over with raisins, steamed broccoli; strawberries over angelfood cakeangelfood cake

• Snack: air popped popcornSnack: air popped popcorn

Very Low Fat Diets

• <10% of calories from fat<10% of calories from fat• May be vegetarianMay be vegetarian• Includes The Pritikin Program and Dean Includes The Pritikin Program and Dean

Ornish’s Program for Reversing Heart Ornish’s Program for Reversing Heart DiseaseDisease

• Elimination of fat makes the diet less Elimination of fat makes the diet less energy denseenergy dense

• May be difficult for some people to adhere May be difficult for some people to adhere toto

Research on Macronutrient Mix in Weight Loss Diets

A Low- Carbohydrate, Ketogenic Diet versus a Low-Fat Diet To Treat Obesity and Hyperlipidemia

• Objective: Compare effects of a low-carb, ketogenic diet Objective: Compare effects of a low-carb, ketogenic diet with those of a low-fat, low chol, reduced calorie dietwith those of a low-fat, low chol, reduced calorie diet

• Design: Randomized, controlled Design: Randomized, controlled • Subjects: 120 overweight, hyperlipidemic volunteersSubjects: 120 overweight, hyperlipidemic volunteers• Intervention: Low carb diet (initially <20 g carb/day) plus Intervention: Low carb diet (initially <20 g carb/day) plus

nutritional supplementation, exercise recommendation, nutritional supplementation, exercise recommendation, and group meetings or low-fat diet (<30% energy from and group meetings or low-fat diet (<30% energy from fat, <300 mg chol, deficit of 500-1000 kcal/d) plus fat, <300 mg chol, deficit of 500-1000 kcal/d) plus exercise recommendation and group meetingsexercise recommendation and group meetings

Yancy, W. S. et. al. Ann Intern Med 2004;140:769-777

Low Carb vs Low Fat Diet

• MeasurementsMeasurements: body weight, body composition, fasting : body weight, body composition, fasting serum lipid levels and group meetingsserum lipid levels and group meetings

• ResultsResults: 76% of the low-carb group and 57% of the low-: 76% of the low-carb group and 57% of the low-fat group completed the study. At 24 weeks weight loss fat group completed the study. At 24 weeks weight loss was greater in the low-carb group (12.9%) than in the was greater in the low-carb group (12.9%) than in the low-fat group (6.7%)low-fat group (6.7%)

• Pts in both groups lost more fat mass (-9.4 kg low carb, -Pts in both groups lost more fat mass (-9.4 kg low carb, -4.8 kg low-fat) than fat free mass (-3.3 kg vs -2.4 kg)4.8 kg low-fat) than fat free mass (-3.3 kg vs -2.4 kg)

• Low carb diet subjects had > decreases in serum Low carb diet subjects had > decreases in serum triglycerides (-74.2 mg.dL vs. -27.9 mg/dL)triglycerides (-74.2 mg.dL vs. -27.9 mg/dL)

Yancy, W. S. et. al. Ann Intern Med 2004;140:769-777

Expected mean body weight over time, by diet group

Low Carb vs. Low Fat• Low carb group had > increases in HDL-C (5.5 mg/dL vs. -Low carb group had > increases in HDL-C (5.5 mg/dL vs. -

1.6 mg/dL P<0.001)1.6 mg/dL P<0.001) • Changes in LDL-C were not significantChanges in LDL-C were not significant• Low carb group had greater participant retention and greater Low carb group had greater participant retention and greater

weight loss over 24 weeksweight loss over 24 weeks• Minor adverse effects were more frequent in the low-carb Minor adverse effects were more frequent in the low-carb

diet groupdiet group• Limitations: Effects of the low-carb diet and of the Limitations: Effects of the low-carb diet and of the

nutritional supplements could not be separated. Participants nutritional supplements could not be separated. Participants were healthy and were followed for only 24 weeks. were healthy and were followed for only 24 weeks.

Yancy, W. S. et. al. Ann Intern Med 2004;140:769-777

Effects of Low-Carbohydrate vs Conventional Weight Loss Diets in Severely Obese Adults: One Year Follow Up of a Randomized Trial

• Objective: Review the 1-year outcomes of two Objective: Review the 1-year outcomes of two groups randomized to these dietsgroups randomized to these diets

• 132 obese adults, BMI 35 or greater; 83% had 132 obese adults, BMI 35 or greater; 83% had diabetes or metabolic syndromediabetes or metabolic syndrome

• Participants were counseled to either restrict carb Participants were counseled to either restrict carb intake to < 30g/day or reduce calories by 500 intake to < 30g/day or reduce calories by 500 cals/day with <30% of cals from fatcals/day with <30% of cals from fat

Stern, L. et. al. Ann Intern Med 2004;140:778-785

Stern, L. et. al. Ann Intern Med 2004;140:778-785

Comparison of mean weight loss in kg between participants on the conventional diet and participants on the low-carbohydrate

diet at 6 months (n = 118) and at 1 year (n = 126)

Low carb vs. conventional 1 year follow up

• By 1 year, mean weight change for persons on the low By 1 year, mean weight change for persons on the low carb diet was -5.1 +/- 8.7 kg compared with -3.1 +/- 8.4 kg carb diet was -5.1 +/- 8.7 kg compared with -3.1 +/- 8.4 kg for persons on a conventional diet. Differences were not for persons on a conventional diet. Differences were not significant (P= 0.20)significant (P= 0.20)

• Triglycerides decreased more on low carb diet, HDL levels Triglycerides decreased more on low carb diet, HDL levels decreased less, HbA1c improved moredecreased less, HbA1c improved more

• Changes in other lipids (LDL, total-C) and insulin Changes in other lipids (LDL, total-C) and insulin sensitivity did not differ between groupssensitivity did not differ between groups

• Limitations: 34% drop out rate, suboptimal dietary Limitations: 34% drop out rate, suboptimal dietary adherence; relatively small net weight loss in both groupsadherence; relatively small net weight loss in both groups

Stern, L. et. al. Ann Intern Med 2004;140:778-785

Low Carb vs. Conventional Diet Outcomes

• Between 6 months and 1 year, persons in the low Between 6 months and 1 year, persons in the low carb group began to regain weight while persons carb group began to regain weight while persons on the conventional diet continued to lose weighton the conventional diet continued to lose weight

• By 6 months, there was no significant difference By 6 months, there was no significant difference in weight loss between the two groupsin weight loss between the two groups

• Intake data suggest that differences in weight Intake data suggest that differences in weight loss, where they exist, are the result of loss, where they exist, are the result of differences in calorie intakes, not a metabolic differences in calorie intakes, not a metabolic advantage of low carbadvantage of low carb

Atkins vs Zone vs Ornish vs Learn

• 311 overweight women ages 20 to 50 were 311 overweight women ages 20 to 50 were randomized to one of four diets randomized to one of four diets incrementally different in CHOincrementally different in CHO

• Subjects were given books explaining the Subjects were given books explaining the diet and attended weekly instruction for diet and attended weekly instruction for eight weeks; then remained on the diets for eight weeks; then remained on the diets for another 10 months (total = 1 year)another 10 months (total = 1 year)

Gardner CD, et al. JAMA 2007;297:969-977

Gardner CD et al. JAMA 2007; 297:969-977.

Changes from baseline at 12 months

OutcomeOutcome AtkinAtkinss

ZonZonee

LEALEARNRN

OrnisOrnishh

Weight (kg)Weight (kg) -4.7-4.7 -1.6-1.6 -2.6-2.6 -2.2-2.2

LDL (mg/dL)LDL (mg/dL) 0.80.8 0.00.0 0.160.16 -3.8-3.8

HDL (mg/dL)HDL (mg/dL) 4.94.9 2.22.2 2.82.8 0.00.0

TriglyceridesTriglycerides -29.3-29.3 -4.2-4.2 -14.6-14.6 -14.9-14.9

Systolic BPSystolic BP -7.6-7.6 -3.3-3.3 -3.1-3.1 -1.9-1.9