Dietary and lifestyle support for people living with obesity: - - PowerPoint PPT Presentation

Dietary and lifestyle support for people living with obesity: update on weight management

Dr Adrian Brown PhD RD NIHR Lecturer/Research Fellow University College London, UK Email: a.c.brown@ucl.ac.uk Twitter: @brownadey

CENTRE OF OBESITY RESEARCH, DEPARTMENT OF MEDICINE

Primose Hill Surgery Patient Participation Group

14th November 2019

Aims of the session

• To quickly and efficiently….
• Set the scene
• Weight Stigma
• What works for what patient?
• Dietary options
• Why is it so hard to keep weight off?
• Behaviour change techniques

“Sudden death is more common in those who are naturally fat than in the lean”

Hippocrates

460 BC – 370 BC

Overweight and obesity worldwide

Overweight Obesity >650 million adults with obesity >1.9 billion

• verweight adults

More than half the adult global population has overweight or obesity in 2016

Normal weight

48% 39% 13%

Changing BMI Distribution & life expectancy

*Based on a meta-analysis of 57 international prospective studies predominantly based in Europe, the United States, Israel, and Australia, including BMI information for 894,576 adults. BMI, body mass index

• 1. Whitlock G, et al. Lancet. 2009; 373:1083–1096.

BMI 30–35 kg/m2 BMI 40–50 kg/m2 Life expectancy reduced ~3 years Life expectancy reduced 8–10 years Each 5 kg/m2 higher BMI

BMI

Healthy weight Overweight Obesity

18.5 25 40+

Severe obesity

30

How many food decisions do we make everyday?

What happens if 10% of the decision encourage weight gain?

Eat Less

It’s simple isn’t it….

Energy balance Energy intake Energy expenditure

Exercise More

&

This is What’s Really Happening….

(Foresight Report UK, 2007)

Obesity is a complex disease: Drivers of

• besity

BMI, body mass index

• 1. Sharma AM et al. Obes Rev 2010;11:362–370; 2. Chesi A et al. Trends Endocrinol Metab 2015;26:711–721
• Central nervous system

pathways

– Hunger and reward

• Brain & Gut signals

– Long-term – Short-term

• High heritability
• f body weight, especially at

BMI extremes

• Genes in hypothalamus

leptin-melanocortin pathway

• Single genetic mutations

leading to obesity are rare, but variations in many genes may predispose to obesity

• Socio-cultural factors

– Traditions, belief systems, peer pressure

• Socio-economic factors

– Education level – Affordability of healthy food

• Food environment

– Availability of inexpensive, highly palatable food with high fat, sugar and salt content

“Genes loads the gun and environment pulls the trigger” (Dr. K. Bock.)

Part of the problem is weight stigma….

• Discrimination or stereotyping based on a person’s weight
• High prevalent in - Media, education, workplace & even healthcare
• Healthcare providers perceived people with obesity as:

Lazy Non-compliant Poorly self controlled Weak-willed Sloppy Dishonest

(Flint, 2016 BJO,; Price et al, 1987; Hebl and Xu, 2001; Foster et al, 2003; Ferrante et al, 2009; Puhl and Heuer, 2009; Huizinga et al, 2009). (UK APPG 2018 Report on Obesity)

Unsuccessful

Dietary management of weight management patient is a dynamic process May require a variety of different dietary changes so flexibility is key

Different Dietary Options for Weight Management

• Stabilising eating pattern (Haus et al 1994; Seagle et al., 2009; Wyatt et al., 2002)
• Low Fat diets (Avenall et al., 2004)
• 600 calorie deficit diet (Avenall et al., 2004)
• Mediterranean Diet (PREDIMED Trial, Estruch et al., 2016)
• Low Glycaemic Index diet (Thomas et al., 2007 & 2009; Ford & Frost, 2010)
• Very low or Low Carbohydrate diet (Mansoor et al., 2015; Tobias et al., 2016)
• Intermittent fasting (Harris et al., 2018)
• Formula diets
• Meal replacements (Franz et al., 2007)
• Very Low and Low Energy Diets (Paretti et al., 2016; Johansson et al., 2014)
• Weight Maintenance (Larsen et al., 2010)

(Franz et al., 2007, JADA, 107 [10]; Avenall et al., 2004)

What percentage of people who lose 5%

• f their body weight through lifestyle intervention maintain this after 5 years?

50–75% 30–40% 20–30% <10%

Maintenance of lifestyle induced weight loss is Challenging

• 30
• 25
• 20
• 15
• 10
• 5

5 Mean change from baseline to end of diet (kg) Mean change from baseline to follow-up (kg)

Anderson et al. Foster et al. Graham et al. Hensrud et al. Jordan et al. Kramer et al. Lantz et al. Murphy et al. S t a l

• n

a s e t a l . Wadden et al. Walsh & Flynn Wadden & Frey P e k k a r i n e n & M u s t a j

• k

i S t u n k a r d & P e n i k

Weight change (kg)

Follow-up range from 4 to 7 years Mann et al. Am Psychol 2007;62:220–33

Why is it so hard to keep weight off?

(Cummings et al., 2002)

Why is weight loss so hard to keep off?

*p<0.001, †p=0.09 vs mean at baseline (Week 0), ‡p=0.008 ITT, intention to treat Sumithran P et al. N Engl J Med 2011;365:1597–1604

95 90 85 80 8 10 18 26 36 44 52 62 Week Weight (kg) All patients (ITT) Completers 40 20 30 60 120 180 240 Post-meal time (min) Desire to eat (mm) 40 20 30 60 120 180 240 Hunger (mm) Week 0 Week 10 Week 62

*

*

*

*

* * † ‡

Why is weight loss so hard to keep off?

*p≤0.001; †p=0.002; ‡p=0.003 vs Week 0 GLP-1, glucagon-like peptide-1; PYY, peptide YY Sumithran P et al. N Engl J Med 2011;365:1597–1604

Fasted

127 41 72 184 35 54 153 38 55

20 40 60 80 100 120 140 160 180 200 Ghrelin GLP-1 PYY

†

* * *

Plasma concentration (pg/mL)

101 48 76 148 48 67 120 44 61

25 50 75 100 125 150 175 Ghrelin GLP-1 PYY

‡

* * *

Plasma concentration (pg/mL)

Post-meal

Week 0 Week 10 Week 62

Impact of weight loss on Energy Expenditure

• Matched groups studied while weight was stable at each stage
• Total energy expenditure, thermic effect of food and resting energy

expenditure were measured

Three groups were matched for weight, fat mass, lean muscle mass, gender and age Rosenbaum M et al. J Clin Invest 2008;118:2583–2591

Usual body weight ≥10 % weight loss sustained for 5–8 weeks ≥10% weight loss >1 year

Resting energy expenditure 60-70% Thermic effect

• f food

10% Activity energy expenditure 10-30%

Persistent reduction of energy expenditure after weight loss

Rosenbaum M et al. Am J Clin Nutr 2008;88:906–912

500 1000 1500 2000 2500 3000 3500

Total daily energy expenditure Resting energy expenditure Activity energy expenditure Thermic effect of feeding

Calories per day (kcal)

Weight loss sustained >1 year Weight loss sustained 5–8 weeks No weight loss

~ 500 kcal

Nothing is in isolation

How do you know when to stop eating?

• Self-monitoring – Food and mood diaries
• Hunger Scale
• Identifying triggers
• Change your environment
• Goal setting – clear and concise – 1-2 goals max

(Wing & Hill, 2001;, Wing & Phelan, 2005, Elfhag & Rossner, 2005, Wing et al., 2008, Butryn et al., 2011, Grace, 2011; Nanchahal, 2007; Wensink, 2007 & 2013)

1 2 3 4 5 6 7 8 9 10

Physically Faint Ravenous Fairly Hungry Slightly hungry Neutral Pleasantly Satisfied Full Stuffed Bloated Nauseous

So where does that leave us?

• Johnston et al. (2014) Meta-analysis
• Significant weight loss was observed with both low-carbohydrate or low-fat diet
• 6-7kg at 12 months follow up compared with no diet – importance of maintenance
• Weight loss differences between individual named diets were small: not clinical

significant

“Recommending any diet that a patient will adhere to in order to lose weight”

Take home messages

• Obesity represent a major threat to global health
• Overweight and obesity are a normal response to an abnormal

environment

• Powerful biological mechanisms hamper weight loss maintenance
• Obesity is a chronic relapsing disease
• Be aware that weight stigma is prevalent within our society - this

needs addressing

• “Find what you love doing and keep doing it!”

Acknowledgments

University College London Team Professor Rachel Batterham, Jed Wingrove, Andrea Pucci, Kusuma Chaiyasoot, Friedrich Jassil, Janine Makaronidis, Jessica Mok, Cormac Magee, Alisia Carnemolla, Roxanne Zakeri, Gemma Montagut-Pino, Nyala Balogum, Jane Fisher University College London Hospital Team

Question?

Thank you for listening Any questions

Extra slides

Dietary factors effecting satiety

• Protein – greater satiety effect than other macronutrients – 50g
• GI Index – more complex. Previous low GI foods more satiating but when

factors such as fibre controlled, GI not significant effect

• Fibre content – Viscous fibres i.e. Petin/guar gum or novel gelling fibres i.e.

Alginates

• Effect maybe related to the amount of fermentable carbohydrate in Low GI diets
• Flavour variety – if offered 3 different type of yoghurt compared with one

ate 23 % more

• Sensory Specific Satiety – senses numbed or satiated if continuously

experience same stimulus

Halton & Hu, 2004; Johnstone et al., 2008; Bornet et al., 2007; Aston et al, 2008; Slavin & Green, 2007 Ford & Frost, 2010; Rolls et al., 1981; Inham, 2001

Dietary factors effecting satiety

• Palatability – pleasure can override signals and increase hedonic stimuli
• Tends to reduce satiation and satiety – can be manipulated
• Portion Size – if offered larger portions will eat them
• Television viewing and other distractions

; Blundell & Finalyson, 2004; Ello- Martin et al., 2005; Bellisle, 2006

Is it all the do with your Genes?

• Twins and family studies have shown how much a contribution genes

plays on body mass index (BMI).

• Large differences in the amount weight is heritable
• Influence of weight higher in children than adults
• Human Thinness
• Individuals with BMI<18kg/m2 & healthy; obesity

(Maes et al, 1997, Behav Genet, 27, 325-351; Elks et al.,2012 Front Endo, 3, 29; Riveros-McKay 2019, PLoS Gen

Chronobiology & Obesity

• Circadian Rhythm – endogenous circadian “clock” over 24 hours anticipate

feeding, fasting and sleep

• Suprachiasmatic Nucleus of hypothalamus
• Blue rich lights – Need to get outside <1% brightness of light outside
• Disruption from shift work and 24 hour lifestyle causing “social jetlag” and

disruption of rhythms

• Sleep reduced by 1.5h over past century (Garaulet, 2010)
• >1/3 adult sleep less than 6hr per night
• Healthy subjects restricted to 4h sleep 6 consecutive nights – impaired

glucose & reduced insulin to glucose challenge

Garaulet et al., 2010, Int J Obesity, Davidson 2006 Curr Biol 16, R914-016; Sutton et al., 2018, Cell Metabolism