Management of obesity and related conditions: Does diet ...

Management of obesity and related conditions: Does diet ...

MANAGEMENT OF OBESITY AND RELATED CONDITIONS: Does Diet Composition Matter? Lisa M. Neff, MD, MS Assistant Professor of Endocrinology Northwestern University Presented 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 MACRONUTRIENT COMPOSITION AND WEIGHT LOSS Expected mean body weight over time, by diet group Low fat -6.5

kg Low carb -12.0 kg Yancy W S et al. Ann Intern Med 2004;140:769-777 2004 by American College of Physicians Dietary Macronutrient Composition and Weight Loss: Positive Studies Study n Duratio Mean Weight Change by n Diet Shai I, 322 2 yr

NEJM, 2008 Gardner 311 1 yr CD, JAMA, 2007 LC - 4.7 kg Med - 4.4 kg LF - 2.9 kg LC (Atkins) - 4.7 kg HP (Zone) -1.6 kg LF (Ornish) - 2.2 kg LF (LEARN) - 2.6 kg LC = low carb, Med = Mediterranean, LF = low fat, HP = high protein

Weight Change Relative to Baseline Gardner, C. D. et al. JAMA 2007;297:969-977. 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 Foster GD, 307 Ann Intern

Med, 2010 Sacks FM, 811 NEJM, 2009 Duratio Mean Weight Change by n Diet 2 yr LC - 6.3 kg LF - 7.4 kg 2 yr LF/SP LF/HP HF/SP

- 3.0 to - 3.6 kg HF/HP LC -13.1 kg LF - 11.6 kg Brinkworth 107 1 yr GD, AJCN, LC = low carb, LF = low fat, HF = high fat, SP = standard 2009 protein, HP = high protein Dietary Macronutrient Composition and Weight Loss: Negative Studies Study n

Duratio Mean Weight Change by n Diet Frisch S, 200 1 yr LC -5.8 kg Cardiovasc LF -4.3 kg Diabetol, 2009 Layman DK, 130 1 yr HP - 9.3 kg J Nutr, 2009 LF - 7.4 kg Keogh JB, 73 1 yr HM -7.6 kg

Br J Nutr, HP - 4.8 kg LC = low carb, HP = high protein , LF = low fat, HM = 2007 high MUFA Dietary Macronutrient Composition and Weight Loss: Negative Studies Study n Duratio n Mean Weight Change by Diet

Ebbeling CB, JAMA, 2007 Das SK, AJCN, 2007 Dansinger ML, JAMA, 2005 73 18 mo LG = LF (~ - 2 kg) 34 1 yr

LG -7.8% LF 8.0% 160 1 yr LC (Atkins) - 2.1 kg HP (Zone) - 3.2 kg LF (Wt Watchers) - 3.0 kg LG = low glycemic load, LC = low carb, HP = high LF (Ornish) -3.3 kg protein, LF = low fat Dietary Macronutrient Composition and Weight Loss: Negative Studies Study n Stern L, 132

Ann Intern Med, 2004 Due A, Int J 50 Obes, 2004 Foster GD, 63 NEJM 2003 Duratio Mean Weight Change by n Diet 1 yr LC - 5.1 kg LF - 3.1 kg 1 yr HP/LF - 6.2 kg

SP/LF - 4.3 kg LC - 4.4% LF - 2.5% 1 yr HP = high protein, LF = low fat, SP = standard protein, LC = low carb Dietary Macronutrient Composition and Body Composition Changes Positive Studies HP > LF Body fat: Layman DK et al., J Nutr, 2009

Negative Studies LC = LF Foster GD, Ann Intern Med, 2010 Brinkworth GD, AJCN 2009 Abdominal fat, waist circ: HM = HP Due A, Int J Obes, 2004 Keogh JB, Br J Nutr, 2007

LG = LF LC > LF Waist circ: Frisch S, Cardiovasc Diabetol, 2009 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 +15 +10 Weight change, kg. + 5 0 -5 10 15 20 25 30

One-Year Changes in Body Weight as a Function of Dietary Adherence Level Dansinger, M. L. et al. JAMA 2005;293:43-53. Weight Loss Outcomes May Be Influenced by Metabolic Profile Ebbeling CB, JAMA, 2007 Pittas A, Diabetes Care, 2005.

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. 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 PARAMETERS IN 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) Glycemic Foods with Index similar carbohydrate content can affect blood glucose levels differently Ludwig, D. S. JAMA 2002;287:2414-2423.

Potato Instant oatmeal White bread

Watermelon Basmati rice Stoneground whole wheat bread Raisins Pineapple Kidney beans Chocolate ice cream Oatmeal made with steelcut oats 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-1 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 resistance TG CRP 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 Diet

Testing #1 Wt Stable on Western Diet Testing #2 2 weeks Inpatient Wt Stable on Wt Stable on DASH Diet Low GI

Diet 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 weeks Inpatient

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