Dietary Approaches

Steps

1. Assessment (who would benefit)

2. Review cause(s) of weight gain
3. Evaluate treatment options – Different
interventions/approach/considerations
for:
- Clinically Obese with multiple
Commorbidities
- Weight Management for
Obese/Overweight without
commorbidities
 How is Adult Obesity Treated?

For select
patients;
3 most Surgery
effective
treatment
Can add 3-
8%
2 placebo-
Pharmacotherapy
subtracted
weight loss
Foundation Diet Physical
of all Activity
1 weight
manageme
nt Lifestyle
approaches
Slide Source: www.obesityonline.org
Modification
Recommendations from The Obesity
Expert Panel Review of Evidence (2013):
1. The greater the individual’s BMI, the greater
the risk of CVD and type 2 diabetes (7,8);
2. Sustained weight loss of as little as 3-5% can
result in meaningful improvements in the health
profile (6);
3. Six months or more of lifestyle counseling
produces the most successful outcomes (9–10);
4. Advise overweight and obese individuals who
have lost weight to participate in a long-term (≥
1 yr) comprehensive weight loss maintenance
program (11,12,13);
Management of Obesity
Goals:
1. Approx: 5-10% weight loss for HEALTH
benefits
2. Weight management without gain
Rate & extent of weight loss: 0.5 – 2
lbs/week (**3500 kcal = 1 lb**)
Steady losses over longer period favor:
• Reduction of fat stores
• Limit loss of protein
• Avoid sharp decline in RMR
Management of Obesity: Steps
• Physical assessment
• Goals (For weight); Short term? Long –term?
• Assessment of current intake
• Estimate Energy Needs (Mifflin & AF)
• Reduction in intake if current intake much
higher than EER (500 kcals may be realistic)
• Can combine with exercise (cardio &
resistance training)
Dietary Approaches for Weight
Management
Dietary approach (without medications or
surgery):
• Usually, overweight/obese without multiple
commorbidities
• Typically involves a Calorie Deficit
• Involves monitoring, (self) or accountability
to coach/counselor
• May also involve exercise/activity
Short-Term Dietary Approaches

• Meal Plan (1800/1500/1200)

• Meal Planning with caloric range
• Diet Analysis with dietitian/CNS
(adjustment of meals, food choices); likely
involves some nutrition education
• “Better Choices” for current selections 
caloric reduction
Longer-Term Dietary Approaches
• Lifestyle & Diet Adjustment
• Sustainable way of eating for long-term
• Incorporates activity
• May incorporate meal planning or
intuitive eating
• Many approaches exist different
approaches work for different people
Dietary Approaches: Evidence for
What Works
• There is no “One Size Fits All” “Diet” for
Weight Loss/Management!
• Different dietary approaches work for
different individuals: The KEY IS
ADHERENCE & CONSISTENCY
• Individualized approach for each client;
need to assess what will work for the
client – based on his/her lifestyle,
preferences etc.
Dietary Approaches: Evidence for What
Works
Several dietary approaches have been
shown to be successful with achieving
weight loss – with adherence & a
calorie deficit
A moderate calorie deficit (10 – 15% of
maintenance intake) is necessary to
achieve weight loss.
However a large/excess deficit is not
recommended for most people (…
Dangers of Excess Restriction

• Reduction in BMR/REE (Long term)

• Unsustainable; relapse
• Potential loss of LBM
• Inability to gain muscle muss (if latter is
desired & combining with resistance training)
• IMPORTANCE of reviewing individual’s
goals
Dietary Approaches: Evidence for What
Works
Research on 15 dietary approaches shows that
they all performed equally well in eliciting short
& long term weight loss in adults – provided that
calories were sufficiently restricted (Nonas)
The 15 Dietary Approaches reviewed include:
1. Diet from the European Association for the
Study of Diabetes Guidelines – targets Food
Groups.
2. Higher protein (25% PRO, 30% Fat, 45%
CHO).
3. Higher protein Zone-type diet (5 meals/day,
Dietary Approaches: Evidence for What
Works
4. Low-carb (initially <20 g/day carb) (Tho carbs
eventually increased; < 20g is in short term).
5. Low-fat (10% - 25% Fat) vegan style diet.
6. Low-fat (20% Fat)
7. Low-glycemic load diet
8. Lower fat (< 30 % fat), high dairy (4
servings/day) diets with or without increased
fiber and/or low-glycemic index/load foods (low-
glycemic load) with prescribed energy
restriction.
Dietary Approaches: Evidence for What
Works
9. Lacto-ovo-vegetarian diet with prescribed
energy restriction.
10. Low fat with prescribed energy restriction.
11. Mediterranean Style diet with prescribed
energy restriction
12. Macronutrient Target Diets (15% or 25%
PRO; 20% or 40% Fat, 35%, 45%, 55%, or 65%
CHO with prescribed energy restriction).
13. High glycemic load or low-glycemic load
with prescribed energy restriction.
Dietary Approaches: Evidence for What
Works
14. Moderate Protein (12% PRO, 58% CHO, 30%
Fat) with Rx’d energy restriction.
15. The American Heart Association (AHA) Step
1 Diet (1500-1800 kcals/ day; < 30% total fat, <
10% sat fat)

NOTE AGAIN: All Diets elicited energy

restriction (calorie deficit)
Considerations
• Goal: Is it Short or long-term?
• What will be a
safe/manageable/sustainable
approach for the individual?
• Comprehensive Lifestyle
Management Approach (Diet +
Physical Activity + Behavioral
Therapy) is shown to be more
effective in sustaining weight loss
Guidelines for Portion The New American Plate
Control

¼
½ STARC
H ¼
http://www.cpmc.org/learning/documents/diabetes-eating.html
http://www.aicr.org/site/PageServer?
pagename=pub_new_amer_plate
Other “Popular Diets”
The Paleo Diet & Primal Diet
IIFYM (If it Fits Your Macros)
Atkins?
Intermittent Fasting
Carb Cycling
Vegan Before 6
Carnivore
Fasting vs Intermittent Fasting

• Fasting: Seldom (if ever) prescribed as

treatment
• Juice Fasts: May be used by some individuals
for “rapid weight loss,” “to feel healthier,”
“mental reset”
> 50% of rapid weight reduction is fluid
Can lead to hypotension; Weight regained
with eating
High ketone production in fasting thought to
suppress appetite
Intermittent Fasting
Intermittent Fasting (IF) (High Kcal vs Low Kcal Days)
Varied approaches:
(i) 5 – 6 days normal intake; 1 day ~ 500 kcals/day
(ii) “Fast for 12-16” hours/day (can include sleep time); eat during the remaining 8 –
12 hours
(iii) 8–hour day diet approach
*Risk for women Intermittent Fasting:
• Hormonal fluctuations (during fasting, insulin sensitivity is affected making
it harder to regulate blood sugar levels, especially in the luteal phase
( second half of the woman’s cycle) when insulin resistance naturally
increases.
• Cortisol spikes (fasting can produce more cortisol; a stress hormone, which
can lead to increased blood sugar levels impacting glucose response)
• Impact on fertility ( fasting disrupts hormones LH and FSH, affecting
ovulation, and menstrual regularity)
• Bone health concerns (lowers bone density in women with low body fat)
Carb Cycling

High Carb vs Low carb days

- Structured around workouts (higher carb
on workout days)
- Carb intake may also vary during day
(pre/post workout)
- Often used by body builders/ fitness &
physique competitors for weight
management
Formula Diets and Meal
Replacement Programs
• May help provide structure & replace other
higher calorie foods
• Examples: SlimFast? Optavia? NJ Diet? Prolon?
• Negative aspects:
• Dependence on particular featured product
• Failure to develop new, appropriate long-
term eating habits
• Focus on weight vs eating for health;
• Failure to learn about “real food” &
portions of real food/ preparation
Meal Replacements

• May be effective/ helpful for some individuals in

short-term; manage calories/portions
• May not be sustainable in L/T
• Does not necessarily help an individual learn
how to eat healthfully L/T, manage & prepare
meals for optimal health
• Risk of nutrient deficiencies, loss of LBM,
motivation
Macronutrient
Profiles of
Popular Diets

de Souza R J et al. Am J Clin Nutr

©2008 by American Society for Nutrition
2008;88:1-11.
Dieting: Which is Best?

Randomized trial of dietary advice

from:
• Atkins Very low carb, high fat
• Zone Moderate carb, moderate fat
• Weight Watchers High carb, moderate fat
• Ornish High carb, very low fat
Study Question: How well do these very different
popular diets work under realistic clinical
conditions over a one-year period?
Answer: All diets had similar effect: 20-25%
of subjects sustained modest weight loss
beyond 1 year; caloric deficit AND adherence
(not the diet) is key
Dansinger ML, et al. JAMA. 2005 Jan 5;293(1):43-53.
Non-Diet Approach: Mindful Eating

Mindful Eating- involves being aware of what you are

sensing, feeling, and thinking as you eat.
Intuitive Eating- involves using your body’s internal cues
like hunger, fullness, and emotion to help guide your food
choices. It rejects the diet mentality and accepts all foods
are acceptable options.
Focuses on achieving health vs a certain wt (longer term,
sustainable)
 Having a healthier relationship with food
Body will attain its natural weight if the individual eats
healthfully, becomes attune to hunger & satiety cues,
incorporates physical activity
Portion Control!
Reduce portion size

Subjects consumed 30% more energy when

offered the largest portion than when offered
the smallest portion
Rolls BJ, et al. Am J Clin Nutr December 2002 vol. 76 no. 6 1207-13. Image: Self Magazine, August 2001.
Remember…
Weight Loss Tip The New American Plate

¼ STARCH

½
¼

http://www.cpmc.org/learning/documents/diabetes-eating.html
http://www.aicr.org/site/PageServer?
pagename=pub_new_amer_plate
Lifestyle Intervention & Counseling
Short Term Weight Loss:
Research shows that for short term
weight loss success, a comprehensive
lifestyle intervention (diet + physical
activity + behavioral therapy on a weekly
basis via a trained professional * in
individual or group sessions) results in
average weight loss of 8 kg (17.6 lbs) in 6
months (~5-10% of initial weight). This is
greater than losses achieved via usual care.
Lifestyle Intervention & Counseling
*Trained professionals include health
professionals such as: RDs, exercise specialists,
psychologists, health counselors)

Counseling provides:
• Analysis
• Assistance with self-reflection
• Feedback
• Accountability
• Avenue for problem solving
• Support
• Nutrition education, planning
Lifestyle Intervention & Counseling
Types of Interventions:
- Face-to- face, individual and/or
group sessions (strong supportive
evidence for weight loss efficacy &
maintenance)
- Electronic (includes self-monitoring
intake/activity & electronic feedback
from trained professional) can produce
weight loss of up to 5 kg at 6 to 12
months
Lifestyle Management
Self Monitoring
Identifying behaviors that may be contributing to
excess intake/ weight gain (mindless eating, stress
eating, or habit)
Emotional Eating- a way to suppress or soothe
negative emotions, such as stress, anger, fear,
boredom, sadness, and loneliness.
Behavior Change  breaking a habit (not always
easy!!)
Stimulus Control is used to change the
likelihood of a behavior being triggered by
changing the stimuli that trigger it.
Stimulus Control

Modification of settings or chain of

events that precede eating
Address/ identify types of foods consumed
when eating does occur (stress eating 
often snack foods vs. healthy choices)
Consequences of eating? Emotional,
Physical?
Cognitive restructuring
Teaches patients to identify, challenge &
correct negative thoughts
Nutrition Counseling & Health
Habits of Weight Loss Success

1. Eating habits
2. Physical activity/exercise
3. Non-exercise activity- daily living other than
exercise (walking to work, gardening, taking
the stairs)
4. Self-monitoring & accountability; mindfulness
5. Setting realistic goals
6. Avoiding excess restriction – maintaining a
healthy balance
7. Identifying & addressing other lifestyle
factors – sleep, stress
8. No fad diets