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  • Body mass index (BMI) represents the relationship between weight and height. It is calculated as weight (in kilograms) divided by height (in meters squared). As shown in this figure, which contains data from 613 men and 876 women, BMI correlates with percent body fat mass in a curvilinear fashion in both men and women [1,2]. The relationship between BMI and percent body fat is sex and age dependent; at an equivalent BMI, women and older persons have a higher percent body fat than men and younger persons. In addition, persons who have a large muscle mass can have an “obese” BMI despite having a normal amount of body fat, while those with excess adiposity and reduced muscle mass can have a “normal” BMI. 1. Gallagher D, Visser M, Sepulveda D, et al. How useful is body mass index for comparison of body fatness across age, sex, and ethnic groups? Am J Epidemiol 1996;143:228-239. 2. Gallagher D, Heymsfield SB, Heo M, et al. Healthy percentage body fat ranges: an approach for developing guidelines based on body mass index. Am J Clin Nutr 2000;72:694-701.
  • Behavioral strategies PA >175 min/week, group sessions and individual meetings, goal of weight loss > 10% was given
  • Quartile of visits and PA similarly were related to initial weight loss
  • *
  • In a systematic evaluation of randomized controlled trials utilizing PMR plans for weight management suggests that these types of interventions can safely and effectively produce significant sustainable weight loss and improve weight related risk factors of disease

SCOPE School Dublin - David Heber SCOPE School Dublin - David Heber Presentation Transcript

  • How to Assess a Patient’s Diet and using LCD and VLCD for Weight loss and Weight Management David Heber, MD,PhD, FACP, FACN Professor of Medicine and Director, UCLA Center for Human Nutrition
  • Disclosures Dr. David Heber has received book royalties and travel reimbursement from Herbalife International.
  • What Influences Food Choices • TASTE Sugar, Fat, and Salt • COST Lowest Cost Foods Have Lowest Nutrient Density (Drewnowski) • CONVENIENCE Quick Serve Restaurants (Fast Foods) Corporate Goal – a store within 7 minutes of every American
  • Our Genes Evolved on Plant-Based Diets Subsistence Agriculture Food Scarcity Adapted to Malnutrition Globalization of the Western Diet Pattern Industrial Agriculture Government Subsidies Increased Availability Poor Food Quality Obesity and Chronic Diseases
  • What are the Differences ? vs. 1. 10% Fat 2. omega-6/omega-3 ratio 3:1 3. Good Fructose with Antioxidants Fiber, Water, Few Calories 4. Plant Proteins with lower calories can be prepared with little fat 5. Rich in Vitamins, Minerals, and Micronutrients 1. 35 to 50% Fat Calories 2. Omega 6/omega 3 ratio 10-30:1 3. Bad Fructose as hidden sugars with High Calories, Low Fiber, Low Antioxidants 4. Animal Protein with Saturated Fat and Increased Calories 5. Poor in Vitamins, Minerals and Micronutrients
  • Sodas Cakes, Pastries, Donuts Burgers/Cheeseburgers Pizza Chips/Popcorn Rice Rolls, buns, muffins, bagels Cheese Beer French Fries 7% 10% 13.8 % 16.8 % 19.7 % 22.4 % 25 % 27.6 % 30.2 % 32.4 % Calorie Contribution of Foods in the American Diet Food Percent of Calories (cumulative)
  • Strategies for Changing the Western Diet and Lifestyle • Increase Physical Activity • Change the Nutritional Environment • Eat less Fat, Saturated Fat and Cholesterol • Eat more Fiber • Eat a diet with plenty of Grains, Vegetables and Fruit • Use alcohol in moderation • Use sugar and salt in moderation • Reduce Stressors
  • Jennifer Anniston used this diet to lose 18 lbs in just 1 month. She recommends this exact diet to anyone looking to lose body fat. Stars such as Kim Kardashian, Britney Spears, and Jennifer Lopez are known for their rapid weight loss. Women's Health magazine uncovers the secret method they used to lose up to 18 pounds of fat in 1 month.
  • Weight Loss Goals of Overweight Women Imagined Goal % of Initial Weight % Reaching Goal Dream Weight - 38% 0% Happy Weight - 31% 9% Acceptable Weight - 25% 24% Disappointed Weight - 17% 20% Below Disappointed ---- 47% 291 lbs 185 lbs
  • A Simple BMI Chart 5'4" Weight (lbs) 5'2" 5'0" 5'10" 5'8" 5'6" 6'0" 6'2" 120 130 150 160 170 180 190 200 210 220 230 240 250140 260 270 280 290 300 6'4"
  • Utility and Limitations of BMI  Permits population-based studies of trends in obesity and is used for clinical guidelines.  Does not correlate well with fat mass in both over- muscled (athletic) and under-muscled (sarcopenic) patients.  Does not reveal differences in fat distribution (visceral vs. subcutaneous).  Does not measure fat directly but correlates with body fat over thousands of average patients.  At any given BMI, women have more fat than men.
  • Lean Body Mass is 70% Water and Conducts Electromagnetic Energy, but Fat Does Not Magnetic Resonance Imaging (MRI)
  • EVEN IF YOU ARE THIN YOU CAN BE FAT MRI reveals fat around the Heart, Liver and Intestine in Individuals with Normal Waist Circumference Of the women scanned by Bell and his colleagues, as many as 45 percent of those with normal BMI scores (20 to 25) actually had excessive levels of internal fat. Among men, the percentage was nearly 60 percent.
  • Many of Us Lose Muscle with Age: InadequateMany of Us Lose Muscle with Age: Inadequate Protein & ExerciseProtein & Exercise Same Weight, Different Muscle MassSame Weight, Different Muscle Mass 21 year old Female (BMI = 24.3 kg/m2 ) 73 year old Female (BMI = 24.5 kg/m2 )
  • Adapted from: Gallagher et al. Am J Clin Nutr 2000;72:694. Body Mass Index (kg/m2 ) 0 10 20 30 40 50 60 70 0 10 20 30 40 50 60 BodyFat(%) Women Men
  • Intra-Abdominal fat Macrophage and the Innate Immune System Pro-Inflammatory Cells Ingress Mediates the Inflammatory State of Adipose Tissue
  • The Difference Between Muscle and Fat Cells Muscle Burns 30 kcal/kg Fat Burns 6 kcal/kg The Best Correlate of Resting Energy Expenditure is the Lean Body Mass So When Muscle is Lost in Sarcopenic Obesity the Resting Metabolic Rate Is Reduced and Weight Gain occurs without a large increase in food intake
  • Could Protein Supplementation During Weight Loss Improve Outcome and Maintain Lean Body Mass ?
  • Dynamics of protein turnover Protein intake 100 g gut Secreted GI Proteins 70 g Fecal loss 10 g Body Protein Turnover 250 g Body protein stores 10,000 g Muscle 50 g Absorbed 160 g Free amino acid “pool” 100 g Liver 25 g Blood cells 28 g Skin 2 g Urinary loss 80 g
  • One Index of Protein Balance is Nitrogen Balance Assess balance at several different protein intakes above and below the estimated requirement level to end up with the RDA. Nbalance = Nintake - Noutput
  • Determining the RDA -40 -30 -20 -10 0 10 20 30 40 0.2 0.4 0.6 0.8 1 Egg Protein Intake (g/kg/day) NitrogenBalance (mgN/kg/day) Young et al. 1973
  • Protein requirements in endurance athletes: Meredith et al. 1989
  • Weightlifters in Balance at 2.5 g/kd/day Tarnopolsky et al. 1992
  • Dietary Reference Intakes (DRIDietary Reference Intakes (DRI)) Acceptable Range of Macronutrient Intake for ProteinAcceptable Range of Macronutrient Intake for Protein Risk of Inadequ acy Risk of Adverse Affects RDRD AA ULUL acceptable intake Protein: 0.8 g/kg 2.5 g/kgProtein: 0.8 g/kg 2.5 g/kg 10% of kcal 35% of kcal10% of kcal 35% of kcal
  • Habitual protein intakes in the U.S.Habitual protein intakes in the U.S. Adapted from Fulgoni, VL. Am J Clin Nutr 2008;87:1554S-1557SAdapted from Fulgoni, VL. Am J Clin Nutr 2008;87:1554S-1557S Mean ± SDMean ± SD
  • Adapted from Fulgoni, VL. Am J Clin NutrAdapted from Fulgoni, VL. Am J Clin Nutr 2008;87:1554S-1557S2008;87:1554S-1557S Lower acceptable macronutrient distribution Upper acceptable macronutrient distribution Error bars indicate 95th percentile Habitual protein intakes in the U.S.Habitual protein intakes in the U.S.
  • Daily patterns of protein intake in younger and olderDaily patterns of protein intake in younger and older adultsadults BkftBkft LunchLunch DinnerDinner SnackSnack TotalTotal Protein intake (g/d)Protein intake (g/d) YoungerYounger 11.111.1 25.425.4 43.043.0 8.88.8 88.388.3 OlderOlder 13.313.3 20.220.2 35.835.8 7.27.2 76.576.5 Protein intake (% of energy)Protein intake (% of energy) YoungerYounger 11.811.8 16.116.1 18.818.8 7.57.5 14.814.8 OlderOlder 13.113.1 16.816.8 18.718.7 8.18.1 15.315.3 Energy intake (kcal/d)Energy intake (kcal/d) YoungerYounger 377377 631631 914914 469469 23912391 OlderOlder 405405 479479 766766 355355 20052005 Adapted from Howarth, NC. Int J Obes 2007;31:675-684
  • Meal Patterns:Meal Patterns: Breakfast ~10 g protein Lunch ~20 g protein Dinner ~60 g protein Unbalanced Protein Distribution response range for protein synthesis (skeletal muscle)
  • Muscle Protein Balance Balance Time Meal Meal Meal Phillips. Nutrition ‘04 Protein accretion Protein loss Protein synthesisProtein synthesis Protein breakdownProtein breakdown
  • Breakfast protein Lunch protein Dinner protein Breakfast ~10 g protein Lunch ~20 g protein Dinner ~60 g protein ~30 g ~30 g ~30 g Balanced Protein Distribution Unbalanced Protein Distribution {Maximum protein synthesis} Meal Patterns:Meal Patterns:
  • Muscle Protein Balance Balance Time breakfast lunch dinner Protein accretion Protein loss Protein synthesisProtein synthesis Protein breakdownProtein breakdown
  • Composition of breakfast mealsComposition of breakfast meals Meal size: 400 kcalMeal size: 400 kcal (gm)(gm) proteinprotein leucineleucine carbohydrcarbohydr fatfat PROPRO 3232 2.702.70 3939 1313 CHOCHO 1212 0.660.66 5959 1212 Layman J. Nutr. 133:411, 2003
  • Maintenance of Lean body mass with higher protein intake Time course changes for the ratio of loss of body fat compared with loss of lean body mass (fat/lean) during weight loss for adult women consuming diets with a carbohydrate (CHO)/protein ratio of 3.5 (CHO Group) or 1.4 (Protein Group). Layman DK et al. J. Nutr. 133:411-417, 2003 fat as % of loss: CHO = 68% PRO = 80%
  • Bars Fruit vegetables low fat curd joghurt Liquid 2 Liter / day Breakfast Snack Lunch Snack Sensible meal MR MR Beipiel für eine vernünftige Mahlzeit Bars Fruit vegetables low fat curd joghurt Partial Meal Replacement Plan
  • Four-year weight losses in the Look AHEAD Study: Factors associated with long-term success in subjects with T2D Wadden et al. Obesity (Silver Spring). 2011;19(10):1987-1998 DSE: Diabetes Support and Education group ILI: Intensive Lifestyle Intervention group Dietary intervention included the intensive use of MR and structured meal plans: The first 4 months 2 MR and 2 SR per day, the following months 5-12, 1 MR and 1 SR per day
  • Wadden TA et al. Obesity Spring) 2009;17(4):713-22 One-year weight losses in the Look AHEAD Study: Factors associated with success Percentage reduction in initial weight at 1 year based on quartile of meal replacement products used. The numbers within each bar shows the mean number of products used in that quartile.
  • Fruit & Vegetable Intake 0 1 2 3 4 5 6 baseline yr 1 yr 2 * * p<0.05 Numberof servings/day Ashley et al Obesity Research 9:S312-S320 (2001) Control Control + MR
  • •Provides fat and lean percentages •Predicts Basal Metabolic Rate •Can calculate protein needs based on Lean Body Mass (0.5 - 1.0 gm/ pound LBM) •Helps establish target weight Bioelectrical Impedance Analysis
  • Body Composition Test Summary Sex: Female Height: 64 inches Age: 47 Weight: 165 TEST RESULTS Percent Body Fat: 38 % Fat Body Weight: 62.7 lbs Lean Body Weight: 102.3 lbs Basal Metabolic Rate 1412 kcal/day
  • Building the Diet • Body composition analysis provides Resting Metabolic Rate (RMR); good first estimate for calories needed for weight loss • Body composition determines lean body mass; up to 1 gram of dietary protein/pound of LBM • For most overweight women, 1200 calorie diet with 75 gm protein per day good starting point; 1500 calories and 100 gm protein for men • Build diet around protein, fruits, vegetables; add whole grains as calories allow
  • Selecting a Meal Replacement • Calories: 300 or fewer • Protein: 15 grams or more • Fat: 5 grams or fewer • Vitamin and Mineral fortified drink or bar • Fiber: at least 5 grams • Vary flavors, textures (drinks, bars, meals • Patients design and tailor their own shake based on protein needs and tastes
  • Building the Diet: Protein First • If possible, determine lean body mass by bioelectrical impedance; diet should supply up to 1 gram of lean protein per pound of lean body mass • If LBM reading not available, most women will need 75-100 grams of protein per day • Aim for two meal replacements per day, providing approximately 25 grams protein each to start
  • Customizing Protein Intake • Lean Body Mass obtained from body composition analysis • Select protein level in closest increment of 25 grams • Use flavored soy or soy/whey protein powder as basis for shake • Mix shake with milk or soy milk • Customize with additional plain protein powder for increased protein/satiety
  • Example • Flavored soy protein powder + nonfat milk = approximately 25 grams protein per shake (15 + 10 grams) • Two shakes per day = 50 grams protein • Protein servings in 25 gram units • Patient requiring 100 grams per day will need two additional units
  • Best Protein Sources (3-4 units per day; 135 calories average) Food Item One Unit Calories Protein (gm) Egg whites 7 whites 115 25 Nonfat cottage cheese 1 cup 140 28 Soy Protein Powder, flv 1 ounce 140 15 (varies Soy Protein Powder, plain 1 ounce 110 20-25 Soy Cereal ½ cup 140 25 (varies) Turkey Breast 3 oz, cooked weight 135 25 Chicken Breast 3 oz, cooked weight 140 25 Lean Red Meat 3 oz, cooked weight 145-160 25 Ocean-Caught Fish 4 oz, cooked weight 130-170 25-31 Shrimp, crab, lobster 4 oz, cooked weight 120 22-24 Tuna 4 oz, water pack 145 27 Scallops 4 oz, cooked weight 135 25 Soy Hot Dog 2 links 110 22 (varies) Soy Ground Round 3/4 cup 120 24 Soy Burgers 2 patties 160 26 Tofu, firm 1/2 cup 180 20 (varies)
  • Add Vegetable Servings 3+ per day, about 55 calories Food Item Portion Calories Fiber Cooked Vegetables Acorn Squash, baked 1 cup 85 6 Artichoke 1 medium 60 6 Asparagus 1 cup 45 4 Beets, cooked 1 cup 75 3 Broccoli, cooked 1 cup 45 5 Brussels Sprouts 1 cup 60 4 Cabbage, cooked 1 cup 35 4 Cauliflower, ckd 1 cup 30 3 Carrots, cooked 1 cup 70 5 Celery, diced 1 cup 20 2 Chinese Cabbage, ckd 1 cup 20 3 Collard greens, ckd 1 cup 50 5
  • Add Fruits 3+ per day, about 70 calories Food Item Portion Calories Fiber Apricots 3 whole 50 3 Avocado ¼ average fruit 80 2 Blackberries 1 cup 75 8 Blueberries 1 cup 110 5 Cantaloupe 1 cup cubes 55 1 Grapes 1 cup 115 2 Honeydew 1 cup cubes 60 1 Kiwi 1 large 55 3 Mango ½ large 80 3 Nectarine 1 large 70 2 Orange 1 large 85 4 Orange Juice ½ cup 50 0 Papaya ½ large 75 3 Peach 1 large 70 3
  • Add Grains 1-2 per day, average 100 calories STARCH/ GRAIN Serving size Calories Fiber (grams) Protein (grams) Cooked Beans ½ cup, cooked 115-140 5-7 7 Brown Rice ½ cup, cooked 110 2 3 Lentils ½ cup, cooked 115 8 9 Whole grain pasta ½ cup, cooked 85 2 3 Shredded Wheat, bite size 1 cup 110 4 5 High Fiber Bran Cereal 2/3 cup 90-120 15-18 4 Oatmeal 1 cup, cooked 130 4 6 Bread, Whole Grain 1 slice 100 3 3-5
  • Sample Weight Loss Diet Plan - 1200 Calories BREAKFAST High Protein Meal Replacement + fruit or 1 cup nonfat yogurt or cottage cheese + fruit or 6 egg white omelet + fruit LUNCH Meal Replacement + fruits and vegetables or 3-4 ounces fish, poultry breast or soy protein + salad, vegetables, and fruit
  • Weight Loss Diet Plan PM SNACK 1 Fruit serving DINNER 6 ounces fish, poultry breast or soy protein substitute 1 grain serving Salad + steamed vegetables Fruit
  • Case Study • Patient is a 42-year-old woman • Married with two teenage children • Works full time • Complains of fatigue, low back pain • Too tired most of the time to exercise • Has sedentary job
  • Case Study, continued • Vital signs: afebrile, BP 140/90, P 72 • Wt: 170 lb Height: 62” • BMI = 31.5 • Waist circumference = 37" • Lab studies: – Total Cholesterol 210 – Triglycerides160 – HDL 32 – FBS 115 mg/dL
  • Body Composition Results • Weight 170 pounds, 62” tall • Fat Mass: 51 pounds; 30.1% body fat • Lean Body Mass: 119 pounds • Estimated RMR: 1642 cal/day • Target weight: 145 lb for body fat of 22%
  • Is this target weight too high? • Yes, she should weigh no more than130 lb at a height of 5'2" for a BMI of 25 • No, she has increased muscle mass compared to other women her age; if she maintains this lean body mass with concomitant fat loss, she will have a normal BMI at 145 pounds
  • Dietary History • Patient relates frequent dieting to keep weight in check • When dieting, she skips breakfast and eats mostly vegetables and small amounts of protein or pasta for entree • No vitamin supplements • When not dieting, she eats pizza, frozen yogurt, and snacks on nuts, cookies, chips • Drinks 3 regular sodas a day
  • Typical “Diet” Day • Breakfast: none, or black coffee and half a grapefruit • Lunch: large green salad with diet dressing • Snack: piece of fruit • Dinner: 2 cups of steamed vegetables, large salad with diet dressing, 1 cup pasta or small chicken breast, fruit for dessert
  • What “red flags” do you see in her dietary history? • No multiple vitamin supplements • Low protein intake • High sugar, high fat foods when not dieting • All of the above
  • Dietary Analysis at a Glance • Patient takes no multiple vitamin supplements, with an apparently very low-calorie intake on ‘diet days’ • Patient takes no calcium supplements, with no apparent dietary sources • Protein intake is marginal: 1 ounce of cooked meat, fish, or poultry provides about 7 grams; patient consumes 20+ grams per day but not every day • Patterns are erratic
  • Resting Metabolic Rate • With LBM of 119 lb, patient burns about 1642 calories per day • Since patient is sedentary, calorie needs are not much higher than this for maintenance • However, she does have more muscle mass than the average woman of her height
  • Protein Requirements • With a LBM of 119 lb, patient requires a 60 - 120 grams per day • Patient currently takes in <30 grams per day on the days she is dieting • Patient needs to increase protein intake to preserve LBM • Meal replacements can help provide adequate protein and organize her eating
  • How much weight will this patient lose on a 1200-caloric diet? • About 1 lb per week • Very little without exercise • 2 lb per week with no difficulty
  • Recommendations for This Patient • Needs adequate dietary protein to maintain LBM: recommend 100 grams per day with 2 meal replacements per day • Patient needs to begin strength training to build muscle and cardiovascular exercise for endurance and to boost calorie expenditure • Each pound of muscle burns 14 calories; if she can build 10 lb of muscle, she can maintain weight on 140 more calories per day
  • Additional Recommendations • Advise patient to use meal replacements and portion-controlled meals to provide proper nutrition with defined calories • Counsel on avoidance of ‘trigger foods’ – Nuts – Mayonnaise, salad dressings, butter, margarine – Cheese and cheese pizza – Ice cream and frozen yogurt – Red meat and fatty fish – Cakes, pies, pastry, and candy
  • Partial Meal Replacement Plan A randomized controlled trial Patients who were transferred to the University Obesity Center for obesity therapy. 1200-1500 kcal/day, 20E% protein, 50-60E% CH, 20-30E% fat for all patients. Weight loss phase: 3 months: partial meal replacement plan with 2 meal replacements, two snack replacements and 1 sensible meal/day versus conventional diet with 3 meals and 2 snacks Weight maintenance phase 4 years: Both diet groups had 1 meal replacement and 1 snack replacement and 2 sensible meals/day
  • Mean Percent Weight Loss Profiles month %weightlossfrombaseline 0 10 20 30 40 50 -15-10-50 Group A Group B Flechtner-Mors, Obes Res 2000 Partial meal replacement plan Weight loss and weight maintenance 2 Shakes as meal replacement 1 Shake as meal replacement Percentagereductionofinitialweight Conventional diet Flechtner-Mors M et al. Obes Res 2000 Months 1 Shake as meal replacement
  • • Weight loss: Two daily Meal Replacements were more effective for weight loss than a traditional meal plan using the same prescribed energy content. • Weight maintenance: One daily Meal Replacement and Snack Replacement was effective in maintaining weight loss for a period of 4 years. Partial meal replacement plan Results
  • Why diets with incorporated meal replacements improve weight loss and weight maintenance • Easier to plan meals • Reduces barriers to dietary adherence • Helps instill regular eating patterns • May increase accuracy of calorie estimation and estimation of portion size • Provides a simple guide for healthy nutrition • Positively affects self-monitoring • Facilitates making less deleterious food decisions