Medically Managed Weight Loss: A Discussion of

Metabolically-directed Nutritional Approaches Wesley Eichorn, DO and Susan Jevert-Eichorn, DO

Assistant Professors

Western Michigan University Homer Stryker M.D. School of Medicine

Department of Family and Community Medicine

August 1, 2019

Disclosure Statement

• Neither of us have a financial relationship with or interest in a commercial interest

• Both presenters restrict carbohydrate intake as part of their dietary patterns and Dr. Eichorn

incorporates fasting as part of his lifestyle

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Objectives

At the conclusion of this presentation, participants will be able to:

1. Examine the risks and benefits of low fat, low carbohydrate, and low-calorie diets in treating obesity

2. Describe the effects of low fat, low carbohydrate, and low-calorie diets on cardiometabolic risk factors

3. Identify strategies for incorporating medically managed weight loss into the family practice setting

“Americans eat too much fat. With

meat, milk, butter and ice cream, the

calorie-heavy U.S. diet is 40% fat, and

most of that is saturated fat—the

insidious kind…that increases blood

cholesterol, damages arteries, and

leads to coronary disease.”

“The only sure way to control blood

cholesterol effectively….is to reduce fat

calories in the average U.S. diet by

more than one-third (from 40% to 15%

of total calories), and take an even

sterner cut (from

17% to 4% of total calories) in saturated

fats.”

Transactions of the Association of

American Physicians 1961

“We propose that carbohydrate-induced

lipemia is a common phenomenon,

especially in the areas of the world

distinguished by caloric abundance and

obesity, whereas fat induced lipemia is

probably a rare familial disorder

encountered in all age groups.”

“It may surprise some readers to learn

that the lipemic plasma was obtained

during the high-carbohydrate period,

and the clear plasma during the high-fat

regimen.”

1977 Dietary Goals for Americans• Increase carbohydrate intake to 55 to 60 percent of calories

• Decrease dietary fat intake to no more than 30 percent of calories, with a reduction in intake of

saturated fat, and recommended approximately equivalent distributions among saturated,

polyunsaturated, and monounsaturated fats to meet the 30 percent target

• Decrease cholesterol intake to 300 mg per day

• Decrease sugar intake to 15 percent of calories

• Decrease salt intake to 3 g per day

“The Dietary Guidelines is a critical tool for professionals to help

Americans make healthy choices in their daily lives to help prevent

chronic disease and enjoy a healthy diet.”

What we have been doing is not

working ….What do we know

and what don’t we know?

Hormones

play a role

Insulin

“Insulin, an anabolic hormone, promotes the storage of

carbohydrate and fat and protein synthesis” (Harrison’s)

Cecil’s

Carbohydrates• 4 kcal/gram

• Can serve as energy source

• Can serve as cellular structural elements

• May contain sugars, starch, and/or fiber

• Break down to monosaccharides

• USDA DRI is 130 grams/day

• No known carbohydrate deficiency

• Not an essential macronutrient

Fat• 9 kcal/gram

• Used as energy source and for many metabolic processes

• Essential fatty acids exist

• Fatty acid deficiency can lead to a disease state

• USDA DRI for fat is at least 30 grams/day

Protein

• 4 kcal/gram

• Contains structural building blocks

• Essential amino acids exist

• Can be used as energy source

• Deficiency can cause Kwashiorkor

• USDA DRI is 0.8 to 2 grams/kg/day

What eating pattern is best?Needs to be

o Safe

o Effective

o One the patient can adhere to

• Definitions:o Low-carbohydrate diet: 50 to 120-

150 grams of carbohydrates per

day

o Very low-carbohydrate: <50 grams

of carbohydrates per day

• Metabolic effects

o Best evidence for weight loss

o Generally improves cholesterol profile

o May reduce blood pressure

o May increase energy expenditure

o Decreased hunger

o Carbohydrate cravings

o May precipitate gout flare

o Kidney disease progression (if severe kidney disease present)

o Malaise - “keto flu”

o Takes several weeks to adapt

Restricted Carbohydrate Diets

Virta Study – 2 year data

90

95

100

105

110

115

120

Baseline 1 year 2 years

Changes in Weight (kg)

Low Carb Usual care

Low Carb Intervention• Reductions in HbA1c, fasting glucose, fasting insulin,

weight, systolic blood pressure, diastolic blood pressure,

triglycerides, and liver alanine transaminase

• HDL increased

• Diabetes

• Decreased diabetes medication use

• Diabetes reversal

Usual Care• Decreased uric acid

• None of the effects listed above for the low carb group

Induction phase:

• Limit carbs to 20 grams per day

• Non-starchy “foundation” vegetables

Ongoing Weight Loss Phase

• Allows wider variety of vegetables, seeds,

nuts

• Some low-glycemic fruit/berries

Pre-maintenance phase:

• Allow carbohydrates to increase as long

as weight doesn’t

Maintenance phase

• 60-90 grams carbs per day limit

• Some more legumes, whole grains, and

fruits okay

Atkins DietAnimal products such as meat, poultry, fish, eggs, and dairy (no low-fat) are mainstays in the diet text

Avoid entirely

• Processed and refined foods (other than low-carb)

• Foods with a high glycemic index

Allowed in more liberal phase but still need to stick to carb count

• Cereals, breads, grains

• Dairy (other than butter or cheese which are allowed in all phases)

• Starchy vegetables

• Most fruit

Atkins Diet

Restricted fat diets - “10 to 30% total calories from fat”

Metabolic effects

o Works for weight loss for some people

o Can reduce fasting blood glucose and insulin

o Decreases LDL AND HDL

o May reduce BP

o Hunger control is difficult

Ornish

Encouraged

• Foods are best eaten in their natural form

• Vegetables, fruits, whole grains, and legumes

• One serving of a soy product each day

• Limited amounts of green tea

• Fish oil 3-4 grams each day

• Small meals eaten frequently throughout the

day

Restrictions

• Limit dietary fat: < 10% of total daily calories

• Limit dietary cholesterol: ≤ 10 mg per day

• Limit sugar, sodium, and alcohol

• Avoid animal products (red meat, poultry, and

fish) and caffeine (except green tea)

• Avoid foods with trans fatty acids, including

vegetable shortening, stick margarines, and

commercially prepared foods, such as frostings;

cake, cookie, and biscuit mixes; crackers and

microwave popcorn; and deep-fried foods

• Avoid refined carbohydrates and oils

Very Low-Calorie Diets• Often delivered via meal replacement products

• Generally delivered in a supervised setting

• Rapid results

• Not generally sustainable

• Long term evidence lacking

Very Low-Calorie DietsMetabolic Effects

• Reduces fasting glucose, insulin,

and triglycerides

• May reduce HDL and LDL

• Reduces blood pressure

Risks

• Fatigue, nausea, constipation, diarrhea, hair loss,

brittle nails, cold intolerance, dysmenorrhea

• Small increase in gallstones, kidney stones, gout

flares

• May have insufficient mineral intake leading to

dysrhythmias, muscle cramps, palpitations

Fasting• Intermittent

• Daily

• Weekly

• Alternate daily

• Prolonged – not recommended except in monitored situations

• Longest recorded is 382 days (13)

• Fasting not recommended for children, pregnant or nursing women or those that are malnourished

Informal Survey … but

interesting

Practical Approach to Evaluating Patients with Obesity

Initial Visit

• Motives

• Prior attempts at weight loss

• Stressors

• Food diaries

• Physical Activity

• Screen for:

• Depression

• Binge Eating disorders

VA Binge Eating Screener

“On average, how often have you eaten

extremely large amounts of food at one time

and felt that your eating was out of control at

that time?”

• Never

• <1 time/week

• 1 time/week

• 2-4 times/week

• 5 + times/week

Testing to Consider in the Evaluation of Patients with Obesity

Comorbidity What to order

Diabetes Fasting glucose level, hemoglobin A1C or 2-hour

oral glucose tolerance test

Insulin resistance Fasting glucose and fasting insulin levels to

calculate HOMA-IR

Hypothyroidism Thyroid stimulating hormone (TSH)

Renal abnormalities Serum creatinine and glomerular filtration rate

(GFR)

Nonalcoholic fatty liver disease Aspartate aminotransferase (AST) and alanine

aminotransferase (ALT), also consider liver

ultrasound

Testing to Consider in the Evaluation of Patients with Obesity

Comorbidity What to order

Hypertriglyceridemia and low high-density

lipoprotein (HDL)

Lipid panel

Gout Uric acid if considering a low carbohydrate diet as

this may temporarily increase the risk of gout

flair

Hypovitaminosis D Vitamin D level

Cardiovascular disease Electrocardiogram particularly if considering

medication therapy

Obstructive sleep apnea Sleep study

Nutrition Counseling Key Points

1. Choose an approach that works for the patient

2. Eliminate sugar and refined carbohydrates

3. Greatly restrict highly processed foods

4. Don't be afraid of saturated fats

5. Eat only 3 meals a day, but aim for less than that

6. Participate in healthy exercise

Common Pitfalls Inhibiting Weight Loss

• Continuing to consume substantial amounts of high calorie drinks

• Excessive intake of sugar-rich candy such as in cough drops

• Using non-nutritive sweeteners

• Prescribing a diet that the patient cannot sustain long term

• Not considering food availability for the patient

Common Pitfalls - Ketogenic Diet

• Eating too many fats

• Not eating enough salt when fasting or starting a ketogenic diet

Questions?