Medically Managed Weight Loss: A Discussion of ...tenant_id/ckeditor_assets/attachments/... ·...
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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?