CENTRE OF OBESITY RESEARCH, DEPARTMENT OF MEDICINE Primose Hill Surgery Patient Participation Group 14 th November 2019 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
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
460 BC – 370 BC “Sudden death is more common in those who are naturally fat than in the lean” Hippocrates
Overweight and obesity worldwide More than half the adult global population has overweight or obesity in 2016 >1.9 billion Overweight overweight adults 39% 48% 13% >650 million Obesity Normal adults with obesity weight
Changing BMI Distribution & life expectancy Life expectancy Life expectancy reduced reduced ~3 years 8–10 years BMI 30–35 kg/m 2 BMI 40–50 kg/m 2 Healthy weight Overweight Obesity Severe obesity BMI 18.5 25 30 40+ Each 5 kg/m 2 higher BMI *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.
How many food decisions do we make everyday? What happens if 10% of the decision encourage weight gain?
It’s simple isn’t it…. Exercise More & Eat Less Energy intake Energy expenditure Energy balance
This is What’s Really Happening…. (Foresight Report UK, 2007)
Obesity is a complex disease: Drivers of obesity • Central nervous system • Socio-cultural factors • High heritability pathways of body weight, especially at – Traditions, belief systems, peer pressure BMI extremes – Hunger and reward • Socio-economic factors • Brain & Gut signals • Genes in hypothalamus – Education level – Long-term leptin-melanocortin pathway – Affordability of healthy food – Short-term • Single genetic mutations • Food environment leading to obesity are rare, – Availability of inexpensive, but variations in many genes highly palatable food with high fat, sugar and salt content may predispose to obesity “Genes loads the gun and environment pulls the trigger” (Dr. K. Bock .) 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
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: Unsuccessful Non-compliant Weak-willed Poorly self controlled Sloppy Dishonest Lazy (UK APPG 2018 Report on Obesity) (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).
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% of 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 n e i k n d o Anderson Wadden Graham i Walsh & Hensrud r s r Wadden Murphy j Kramer Foster Jordan a a a a Lantz k k t k n & Frey i s n Flynn k n et al. et al. et al. et al. o . et al. et al. et al. et al. u et al. u e e l l a M a P t P 5 t S t S & & e 0 Weight change (kg) -5 -10 -15 -20 -25 -30 Mean change from baseline to end of diet (kg) Mean change from baseline to follow-up (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? Week 0 Week 10 Week 62 * Hunger (mm) 40 95 * * Weight (kg) All patients (ITT) 20 90 * 0 85 * 0 30 60 120 180 240 Completers 80 * † Desire to eat (mm) 0 0 8 10 18 26 36 44 52 62 40 ‡ Week 20 0 0 30 60 120 180 240 * p <0.001, † p =0.09 vs mean at baseline (Week 0), ‡ p =0.008 Post-meal time (min) ITT, intention to treat Sumithran P et al. N Engl J Med 2011;365:1597–1604
Why is weight loss so hard to keep off? Fasted Post-meal Week 0 * * 175 200 Week 10 Plasma concentration (pg/mL) Plasma concentration (pg/mL) 184 148 180 ‡ Week 62 150 153 160 120 125 140 127 101 120 100 * 100 76 * 75 67 * * 72 61 80 48 48 54 55 † 44 60 50 41 38 35 40 25 20 0 0 Ghrelin GLP-1 PYY Ghrelin GLP-1 PYY * 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
Impact of weight loss on Energy Expenditure Resting energy Thermic effect expenditure of food Activity energy 10% expenditure 10-30% 60-70% ≥10 % weight loss ≥10% weight loss Usual body weight sustained for 5–8 >1 year weeks • 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
Persistent reduction of energy expenditure after weight loss 3500 Calories per day (kcal) 3000 No weight loss ~ 500 kcal Weight loss sustained 5–8 weeks 2500 Weight loss sustained >1 year 2000 1500 1000 500 0 Total daily energy Resting energy Activity energy Thermic effect of expenditure expenditure expenditure feeding Rosenbaum M et al. Am J Clin Nutr 2008;88:906–912
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 1 2 3 4 5 6 7 8 9 10 Physically Ravenous Fairly Slightly Neutral Pleasantly Full Stuffed Bloated Nauseous Faint Hungry hungry Satisfied ( Wing & Hill, 2001;, Wing & Phelan, 2005, Elfhag & Rossner, 2005, Wing et al., 2008, Butryn et al., 2011, Grace, 2011; Nanchahal, 2007; Wensink, 2007 & 2013)
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
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