Dietary approaches for the approaches for the treatment of obesitytreatment of obesity

Amanda Hallson (Amanda Hallson (MSc.,RDMSc.,RD))

Dietitian in Obesity ManagementDietitian in Obesity Management

OverviewOverview

• BDA Position Paper on obesity BDA Position Paper on obesity treatmenttreatment

• What we did then…What we did then…• Current evidence baseCurrent evidence base• Dietary intervention in GCWMSDietary intervention in GCWMS• Nutritional resourcesNutritional resources• Current and future debateCurrent and future debate

BDA Position PaperBDA Position PaperObesity treatment: future directions Obesity treatment: future directions

for the contribution of dietitiansfor the contribution of dietitians

First published in First published in Journal of Human NutritionJournal of Human Nutrition and Dietetics and Dietetics (1997)(1997)

• Addressed strategies which dietitians could use to Addressed strategies which dietitians could use to promote weight loss and weight maintenance in obese promote weight loss and weight maintenance in obese adultsadults

• Recognised that both prevention & treatment of obesity Recognised that both prevention & treatment of obesity are complex and difficult endeavoursare complex and difficult endeavours

• Dietitians are well positioned to provide evidence based, Dietitians are well positioned to provide evidence based, independent information on nutrition & eating behaviour independent information on nutrition & eating behaviour in the management of obesityin the management of obesity

Past dietary advicePast dietary advice

• Simplicity of approachSimplicity of approach• Individuals severely restricting their energy Individuals severely restricting their energy

intakeintake• Proved to be ineffective in the long termProved to be ineffective in the long term• Hence ethically questionableHence ethically questionable• Weight cycling – Binge eating disorderedWeight cycling – Binge eating disordered• Developing and evaluating different types of Developing and evaluating different types of

treatment approaches treatment approaches

Obesity can only occur when Obesity can only occur when energy intake remains higher energy intake remains higher than energy expenditurethan energy expenditure

Adipose tissue

Energy Intake

Energy Expenditure

Reasons…Reasons…

Availability of energy dense foodsAvailability of energy dense foods A move away from the traditional dietA move away from the traditional diet A decrease in cooking, menu planning and A decrease in cooking, menu planning and

shopping skillsshopping skills An increase in the consumption of snacks and An increase in the consumption of snacks and

sugar based beveragessugar based beverages Food portion sizesFood portion sizes Significant growth in the UK market for fast food Significant growth in the UK market for fast food

and takeaway outlets. and takeaway outlets.

Decrease in energy expenditureDecrease in energy expenditure

ActivityActivity Kcal/week Kcal/week 1950’s1950’s

Kcal/week Kcal/week 20002000

Food shoppingFood shopping 2400 (on foot) 276 (driving)

Washing Washing clothesclothes

1500 (by hand) 270 (washing machine)

HeatingHeating 1300 (making a coal fire)

Almost zero

(thermostat)

Making a bedMaking a bed 575 (with blankets)

300 (with duvet)

Energy Balance

• Accumulation of only 50 - 200 kcal daily leads over 4 -10 year period to a slow and progressive weight increase 2-20kg

• Each extra 10kg of weight indicates an extra 70,000 stored kcal

• A woman of average height and a BMI of 30 kg/m2 has about 105,000 excess kcal stored

DrinkDrink CaloriesCalories Why?Why? How much?How much?330ml fizzy drink330ml fizzy drink 134134 SugarSugar 36g = 7 tsp36g = 7 tsp

Large wholeLarge whole

milk vanilla milk vanilla

lattelatte

364364 SugarSugar

FatFat

42g = 10.5 tsp42g = 10.5 tsp

14g = 3 tsp oil14g = 3 tsp oil

125ml white 125ml white

winewine8282 Sugar & Sugar &

alcoholalcohol82g = 4 tsp82g = 4 tsp

250ml fruit 250ml fruit smoothiesmoothie

160160 SugarSugar 30g = 8 tsp30g = 8 tsp

SIGN Key Questions…SIGN Key Questions…

Which dietary interventions are most effective in producing

and maintaining a 5kg/5% weight loss at

12 months ?

Classification of diet typesClassification of diet types

Diet Type Description Commercial Example

Energy deficit or Low Energy Diet (LED)

600 kcal deficit diet Weight Watchers

Low fat diet (LF) <30% total daily energy from fat

Commercial Slimming organisations

Very Low Fat (VLF) <10% total daily energy from fat

Ornish and LEARN

Low Calorie (LCD) >800 – 1600 kcals/day

Weight WatchersWeight Watchers

/Slimming World/Slimming World

Very Low Calorie

(VLCD)

< 800 kcals/day Cambridge & Lighter Cambridge & Lighter Life (Liquids)Life (Liquids)

Low Carbohydrate, Protein Sparing

Modified Fast (PSMF)

<50g Carbohydrate/day

Atkins

What is an energy deficit diet ?What is an energy deficit diet ?

Theory of energy deficit diet

Modify type, quantity, frequency of food and drink => hypo caloric intake.Weight loss 0.5 kg/ week = body fat loss 0.5 kg/ week => 3,500 kcals Requires energy deficit of at least 600 kcals per day.

Can be achieved by

•600kcal deficit, •low fat diets, •moderate energy prescription, •low or very low calorie diets, •protein-sparing modified fast•low carbohydrate low fat diets

How effective is an energy deficit diet

A comprehensive HTA comparing various dietary interventions with a minimum of 12 months follow up.

Median weight change across 12 comparisons was –4.6 kg (range –0.60 kg to –7.20 kg) for a 600 kcal deficit diet or low-fat diet

+0.60 kg (range +2.40 kg to –1.30kg) for usual care.

. NICE Evidence table 15:14 (2006) 1++SIGN 115 (2010) 1++

Which diet type is most effective in Which diet type is most effective in

achieving a 5kg weight loss targetachieving a 5kg weight loss target

Do they work ?

Low calorie diets (1,000-1,600 Kcal/day) and very low calorie diets (1000 Kcal/day) are associated with modest weight loss (5-6%) at 12 months follow up. 1++ Douketis, J.D., Macie, C., Thabane, L. and Williamson, D.F. (2005

Although VLCD are associated with greater weight loss in the short term (three to four months) this difference is not sustained at 12 months’ 1- Gilden, T. et al (2006)

Low Calorie Diets (LCD)

Which works best ?

Very Low Calorie Diets (VLCD)

Low Fat Diets Low Carbohydrate diets

Do they work ?Both low carbohydrate (< 30 g/day) and low fat (< 30% of total daily energy intake from fat) diets are associated with modest weight loss (5kg) at 12 months. At six months there is significant difference in favour of low carbohydrate diets but this is not maintained at 12 months .Nordmann, A.J,(2006) 1++

Which works best ?

There was no significant difference between low fat diets and a range of other dietary interventions at 18 months’ Cochrane Review (2007) 1++

Which diet type is most effective in achieving a 5kg weight loss target ?

A A RecommendationRecommendationDietary interventions for weight loss should be calculated to produce a Dietary interventions for weight loss should be calculated to produce a

600 Kcal/day energy deficit. 600 Kcal/day energy deficit. Programmes should be tailored to the dietary preferences of the Programmes should be tailored to the dietary preferences of the

individual patient.individual patient.

Good Practice PointGood Practice PointDiscussion around dietary change should emphasise achievable and Discussion around dietary change should emphasise achievable and

sustainable healthy eating.sustainable healthy eating.

DD Recommendation Recommendation

Where very low calorie diets are indicated for rapid weight loss, these Where very low calorie diets are indicated for rapid weight loss, these should be conducted under medical supervision.should be conducted under medical supervision.

Recommendations

Dietary Advice inDietary Advice in GCWMS GCWMS

Personal Dietary PrescriptionPersonal Dietary Prescription Calculate Energy required – 600kcal 0.5kg Calculate Energy required – 600kcal 0.5kg

loss / weekloss / week Give portion list of 5 basic food groupsGive portion list of 5 basic food groups Balanced number of portions of each food Balanced number of portions of each food

group spread through out the daygroup spread through out the day Record daily intake and aim to match toRecord daily intake and aim to match to

Recommended prescriptionRecommended prescription

600 kcal deficit diet

Example using the Mifflin equationExample using the Mifflin equation

Female 32 years oldFemale 32 years old

Weight 133kg Height: 1.68 mWeight 133kg Height: 1.68 m

(9.99 x weight in Kg) + (6.25 x height in cm) (9.99 x weight in Kg) + (6.25 x height in cm) - (4.92 x age) – 161 x 1.27 PAL- (4.92 x age) – 161 x 1.27 PAL

2616kcals – 600kcals = 2616kcals – 600kcals = 2016 kcals/day 2016 kcals/day

Personalised Dietary Prescription of 2000 calories per day

Food Group Portions recommended per day

Starches 8

Fruit and Vegetables 88

Dairy 33

Meat, Fish & Alternatives

33

Fats (butter, low fat spreads, mayonnaise, ghee, salad creams)

33

Extras 200 calories200 calories

20

2000 kcal

8 Portions

Fruit & Veg

8 Portions

Starch

Meat

3 Fat

3

Dairy

3

200 kcal

22

2000 Calorie Day2000 Calorie DayBreakfastBreakfast

Starches Starches

DairyDairy

FatFat

FruitFruit

MeatMeat

1

1

1

1

+2

1/2

23

StarchesStarches

DairyDairy

FatFat

Fruit & VegFruit & Veg

Meat/FishMeat/Fish

LunchLunch

2

1

1

1

+1

1 +1

Whole Day 2000 CaloriesWhole Day 2000 Calories

8 Starch 8 Starch

8 Fruit & Veg 8 Fruit & Veg

3 Dairy 3 Dairy

3 Meat/Fish 3 Meat/Fish

3 Fat 3 Fat

Extras 200 kcalExtras 200 kcal

Total Portions

Count the Portions or CaloriesCount the Portions or Calories

Ingredients1 medium sized baked potato

4 heaped dessertspoons baked beans Match box size piece of cheese (30g)

Salad optional

Importance of Food DiariesImportance of Food Diaries

• Self monitoring is an Self monitoring is an important behavioural important behavioural strategy (O’Neill, 2001)strategy (O’Neill, 2001)

• Evidence to support Evidence to support those that have lost those that have lost weight and successfully weight and successfully maintained weight loss maintained weight loss for >2 yrs have regular for >2 yrs have regular self monitoring as a self monitoring as a feature (Colvin et al, feature (Colvin et al, 1983)1983)

Phase 2Phase 2

Fail to lose 5kg through 600 kcal deficit diet and Fail to lose 5kg through 600 kcal deficit diet and portion controlportion control

Options: To try a structured Low Calorie Diet or Options: To try a structured Low Calorie Diet or medicationsmedications

Structured Low Calorie DietStructured Low Calorie Diet

1200 calories per day • 300 calorie breakfast choices• 400 calorie lunch choices• 500 calorie evening meal, chosen from selection of protein, carbohydrate, vegetable and dessert options

1500 calories per day

As above but also includes 100 calorie snacks, up to 3 per day.

LCD & Meal replacementsLCD & Meal replacements

Low Calorie Diet may also include the use of Meal Replacement supplements e.g.

SlimfastBuild-Up ComplanSupermarket own brands

These can be used instead of breakfast and/or lunch, if it fits in with your lifestyle.

ResourcesResources

Food DiariesPortion bookletsSample menusRecipesManualsLabel reading guides

Current dialogue/debateCurrent dialogue/debate

Sweden’s new dietary Sweden’s new dietary guidelinesguidelines

Dietary approaches – key pointsDietary approaches – key points

• Understand the position at the beginning of treatment through a comprehensive assessment

• Stabilise eating pattern

• Improve the nutritional quality of the diet

• Achieve negative energy balance

• Promote self-monitoring

Thank you

Amanda Hallson (RD)

Greater Glasgow & Clyde Weight Management Service

Tel: (0141) 201-6155

Email: amanda.hallson@ggc.scot.nhs.uk

ReferencesReferences• British Dietetic Association (1997) Position Paper – Obesity treatment: future British Dietetic Association (1997) Position Paper – Obesity treatment: future

directions for the contribution of dietitians. directions for the contribution of dietitians. Journal of Human Nutrition and Dietetics Journal of Human Nutrition and Dietetics 10, 95-10110, 95-101

• Freedman M.R, King J and Kennedy E (2001) Popular Diets: A Scientific Review. Freedman M.R, King J and Kennedy E (2001) Popular Diets: A Scientific Review. Obesity Research 9 Suppl.1 March Obesity Research 9 Suppl.1 March

• Department of Nutrition Harvard School of Public Health available online at: Department of Nutrition Harvard School of Public Health available online at: http://www.hsph.harvard.edu/http://www.hsph.harvard.edu/

• Haslam D. W and James W.P.T (2005).Haslam D. W and James W.P.T (2005). Obesity.Obesity. The LancetThe Lancet 366:1197-209. 366:1197-209.• NDR 2012 (Nutrition and Diet resources) NDR 2012 (Nutrition and Diet resources) Weight loss you can see on a plateWeight loss you can see on a plate• NHS Health Development Agency (2003). The Management of obesity and NHS Health Development Agency (2003). The Management of obesity and

overweight. Available online at: overweight. Available online at: www.hda.nhs.ukwww.hda.nhs.uk• NICE – guidelines for obesity in final consultation phase (2006) Available online at: NICE – guidelines for obesity in final consultation phase (2006) Available online at:

www.publichealth.nice.org.ukwww.publichealth.nice.org.uk • PHEL – Public Health Electronic Library available online at: PHEL – Public Health Electronic Library available online at: www.phel.gov.ukwww.phel.gov.uk• The Cochrane Collaboration – Available online at: The Cochrane Collaboration – Available online at: www.cochrane.org/reviewswww.cochrane.org/reviews • SIGN 115 (2010)SIGN 115 (2010)