MANAGEMENT OF OBESITY AND RELATED CONDITIONS: Does Diet Composition Matter? Lisa M. Neff, MD, MS...
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Transcript of MANAGEMENT OF OBESITY AND RELATED CONDITIONS: Does Diet Composition Matter? Lisa M. Neff, MD, MS...
MANAGEMENT OF OBESITY AND RELATED CONDITIONS:Does Diet Composition Matter?
Lisa M. Neff, MD, MSAssistant Professor of EndocrinologyNorthwestern UniversityPresented at Obesity 2010, San Diego, CA
Objectives
To review the evidence regarding the effects of dietary macronutrient composition on weight loss outcomes.
To review the evidence regarding the effects of diet composition on metabolic parameters in the absence of weight loss. the DASH diet the low glycemic index diet
DIETARY MACRONUTRIENTCOMPOSITION AND WEIGHT LOSS
Expected mean body weight over time, by diet group
Yancy W S et al. Ann Intern Med 2004;140:769-777
©2004 by American College of Physicians
Low fat -6.5 kg
Low carb -12.0 kg
Dietary Macronutrient Composition and Weight Loss: Positive Studies
Study n Duration
Mean Weight Change by Diet
Shai I, NEJM, 2008
322 2 yr LC - 4.7 kgMed - 4.4 kgLF - 2.9 kg
Gardner CD, JAMA, 2007
311 1 yr LC (Atkins) - 4.7 kgHP (Zone) -1.6 kgLF (Ornish) - 2.2 kgLF (LEARN) - 2.6 kg
LC = low carb, Med = Mediterranean, LF = low fat, HP = high protein
Gardner, C. D. et al. JAMA 2007;297:969-977.
Weight Change Relative to Baseline
Predicted absolute mean change in body weight for participants in the low-fat and low-carbohydrate diet groups, based on a random-effects linear model.
Error bars represent 95% CIs.
Foster G D et al. Ann Intern Med 2010;153:147-157
©2010 by American College of Physicians
Dietary Macronutrient Composition and Weight Loss: Negative Studies
Study n Duration
Mean Weight Change by Diet
Foster GD, Ann Intern Med, 2010
307 2 yr LC - 6.3 kgLF - 7.4 kg
Sacks FM, NEJM, 2009
811 2 yr LF/SP LF/HP HF/SP - 3.0 to - 3.6 kgHF/HP
Brinkworth GD, AJCN, 2009
107 1 yr LC -13.1 kgLF - 11.6 kg
LC = low carb, LF = low fat, HF = high fat, SP = standard protein, HP = high protein
Dietary Macronutrient Composition and Weight Loss: Negative Studies
Study n Duration
Mean Weight Change by Diet
Frisch S, Cardiovasc Diabetol, 2009
200 1 yr LC -5.8 kgLF -4.3 kg
Layman DK, J Nutr, 2009
130 1 yr HP - 9.3 kgLF - 7.4 kg
Keogh JB, Br J Nutr, 2007
73 1 yr HM -7.6 kgHP - 4.8 kg
LC = low carb, HP = high protein , LF = low fat, HM = high MUFA
Dietary Macronutrient Composition and Weight Loss: Negative Studies
Study n Duration
Mean Weight Change by Diet
Ebbeling CB, JAMA, 2007
73 18 mo LG = LF (~ - 2 kg)
Das SK, AJCN, 2007
34 1 yr LG -7.8%LF – 8.0%
Dansinger ML, JAMA, 2005
160 1 yr LC (Atkins) - 2.1 kgHP (Zone) - 3.2 kgLF (Wt Watchers) - 3.0 kgLF (Ornish) -3.3 kg
LG = low glycemic load, LC = low carb, HP = high protein, LF = low fat
Dietary Macronutrient Composition and Weight Loss: Negative Studies
Study n Duration
Mean Weight Change by Diet
Stern L, Ann Intern Med, 2004
132 1 yr LC - 5.1 kgLF - 3.1 kg
Due A, Int J Obes, 2004
50 1 yr HP/LF - 6.2 kgSP/LF - 4.3 kg
Foster GD, NEJM 2003
63 1 yr LC - 4.4%LF - 2.5%
HP = high protein, LF = low fat, SP = standard protein, LC = low carb
Dietary Macronutrient Composition and Body Composition ChangesPositive StudiesHP > LF Body fat:
Layman DK et al., J Nutr, 2009
Abdominal fat, waist circ: Due A, Int J Obes, 2004
LC > LF Waist circ:
Frisch S, Cardiovasc Diabetol, 2009
Negative StudiesLC = LF Foster GD, Ann Intern
Med, 2010 Brinkworth GD, AJCN
2009
HM = HP Keogh JB, Br J Nutr, 2007
LG = LF Ebbeling CB, JAMA, 2007 Das SK, AJCN, 2007
HP = high protein, LF = low fat, LC = low carb, HM = high MUFA, LG = low glycemic load
Individual percent weight changes at 2 year for 270 subjects completing the DIRECT intervention, comparing a low fat diet, a Mediterranean diet, and a low carb diet. From Greenberg I, J Am Coll Nutr, 2009
Dansinger, M. L. et al. JAMA 2005;293:43-53.
One-Year Changes in Body Weight as a Function of Dietary Adherence Level
Weig
ht
ch
an
ge,
kg
.
0
-5
+5
-10
-15-20-25-30
+10
+15
Weight Loss Outcomes May Be Influenced by Metabolic Profile Ebbeling CB, JAMA, 2007
Subjects with high insulin secretion after an OGTT lost more weight (and more fat) on a low GL diet than on a standard LF diet. Those with low insulin secretion lost the same with a low GL or LF diet.
Pittas A, Diabetes Care, 2005. Subjects with high insulin secretion after an OGTT lost
more weight on a HP, low GL diet than on a high carb, high GL diet. Those with low insulin secretion tended to lose more weight with a high GL diet (NS).
Cornier MA, Obes Res, 2005. Insulin sensitive women lost more weight with a LF diet,
whereas insulin resistant women lost more weight with a HP diet.
However…
Other studies suggest low fat, low carb, and low glycemic load diets are equally effective for long-term weight loss in patients with type 2 diabetes: Davis NJ, Diabetes Care, 2009 Wolever TM, AJCN, 2008 Brinkworth GD, Diabetologia, 2004
DIETARY COMPOSITION AND METABOLIC PARAMETERSIN THE ABSENCE OF WEIGHT LOSS
The DASH Diet
High in fruits and vegetables (typically 10 servings/day or more), whole grains, and low fat dairy products(2-3 servings/day or more)
Moderate amounts of nuts, beans, fish and poultry
Limited red meat, fried foods, and sweets Low in cholesterol, saturated fat, sugars,
and sodium High in calcium, magnesium, potassium,
vitamins, phytochemicals, and fiber
The DASH Diet
High in fruits and vegetables (typically 10 servings/day or more), whole grains, and low fat dairy products(2-3 servings/day or more)
Moderate amounts of nuts, beans, fish and poultry
Limited red meat, fried foods, and sweets Low in cholesterol, saturated fat, sugars,
and sodium High in calcium, magnesium,
potassium, vitamins, phytochemicals, and fiber
The DASH Diet
At weight stability, the DASH diet: Lowers blood pressure in normotensive and
hypertensive adults (Appel, NEJM 1997, Sacks, NEJM 2001)
Reduces LDL cholesterol (Obarzanek, AJCN 2001)
But, it may also: Reduce HDL cholesterol, like other low-fat
diets (Obarzanek, AJCN, 2001) Increase TG in some patients, like other high
carbohydrate diets (Erlinger, Circulation, 2003)
The DASH Diet
Weight loss studies suggest the diet: May reduce fasting glucose and improve
insulin sensitivity more than standard weight loss diets (Azadbakht, Diabetes Care 2005, Ard, Diabetes Care 2004)
May reduce inflammatory markers such as C-reactive protein and increase levels of adiponectin (Lien, Obesity, 2006)
May increase antioxidant capacity and reduce oxidative stress (Lopes, Hypertension, 2003)
Ludwig, D. S. JAMA 2002;287:2414-2423.
Foods with similar carbohydrate content can affect blood glucose levels differently
Glycemic Index
Potato Instant oatmeal White bread Watermelon
Basmati rice Stoneground whole wheat
bread Raisins Pineapple
Kidney beans Chocolate ice cream Oatmeal made with steel-
cut oats Spaghetti, al dente
Low Glycemic Index Diets
Without weight loss, low GI diets: Reduce postprandial glucose levels in
normal individuals and people with diabetes (Ludwig, JAMA, 2002)
Produce modest improvements in HbA1c in patients with diabetes (Thomas D, Cochrane Database Syst Rev, 2009)
May or may not affect insulin sensitivity
Low Glycemic Index Diets
Without weight loss, low GI diets may:
increase HDL (Luscombe, EJCN, 1999)
reduce inflammatory markers such as IL-1β and IL-6 (Kallio, AJCN, 2008)
increase antioxidant capacity (Botero, Obesity, 2009)
Low Glycemic Index Diets
With weight loss:In overweight and obese adults (n=39), a low GI diet produced greater improvements in the following, as compared to a low fat diet (despite identical weight loss of 10%) :
insulin resistanceTGCRP blood pressure(Pereira MA, JAMA, 2004)
Summary
Dietary macronutrient composition does not influence weight loss outcomes in the general population.
Dietary adherence influences weight loss outcomes.
Other factors (such as insulin resistance) might influence weight loss outcomes.
Dietary micronutrient and macronutrient composition may influence metabolic parameters in the absence of weight loss.
Future Directions
Wt Stable on Western
DietTesting
#1
Wt Stable on Western
Diet
Wt Stable on DASH Diet
Wt Stable on Low GI
DietTesting #2 Testing #2 Testing #2
Subjects: n=39, ages 18-65, with insulin resistance and the metabolic syndrome.
Outcomes: insulin sensitivity, glycemic control, lipids, blood pressure, inflammatory markers
2 weeksInpatient
2 weeksInpatient