Great Diets for Weight Reduction

Dr. Clarence P. Davis

Bergstrasse 8

CH-8702 Zollikon

Diet and/or behavior modification:

Long-term results

(adapdet from Wadden TA. Ann Intern Med 1993; 119:688-93)

VLCD

Modified diet + behavior modification

VLCD + behavior modification

WE

igh

t ch

an

ge (

kg

)

-201 2 3

Years after interventionIntervention

4 5

-15

-10

-5

0

-5

-16

-14

-12

-10

-8

-6

-4

-2

0

20 6 18

Behavior modification

Standard behavioralTreatment (SBT)

SBT + structeredmeal plans

SBT + fat reduction

SBT + caloricrestriction

SBT + walkingprogram 3d/week

[months]

[weight loss % of initial weight][Sherwood et al. Int J Obes 1999;23:485-93

Focus of every overweight

therapy

should lie on a

LIVELONG

continuing

weight reduction

activity

milleniums centuries decades

Cause: Genetics versus

Environment

Catherine Christie, PhD, RD, LD/N, 2003

OBESITY

Prof. P James, et al., IOTF Unpublished Data.

Obesity Rates Could Double in

25 Years

Population percentage

with BMI > 30kg/m2

BIG EATER

Definition: BIG EATER

• Has no or only short lasting feeling of satiety

• Eats at least once a day more than a normal

restaurant size serving

• Usually not more than 4 meals per day

• No feelings of discomfort even after very

opulent meals.

BBC 2003:

Fast food 'as addictive as heroin'http://news.bbc.co.uk/1/hi/health/2707143.stm

NEWS Tbo 2004:

Fast Food As Health Food?

http://news.tbo.com/news/MGALX4Y1WPD.html

BBC 2002

Snack food sales rockethttp://news.bbc.co.uk/1/hi/uk/226

2816.stm

BB2 2002

Junk food battle hits US schoolshttp://news.bbc.co.uk/1/hi/world/americas/2016819.stm

BBC 2003

'Big portions' health warninghttp://news.bbc.co.uk/1/hi/health/3112718.stm

Hamburgers are 112% bigger than they were 20 years ago

BBC 2003

Court dismisses McDonald's obesity casehttp://news.bbc.co.uk/1/hi/world/americas/2685707.stm

Increased Portion Sizes

Catherine Christie, PhD, RD, LD/N, 2003

Comparison of Energy Densities

Nielsen SJ et al JAMA. 2003 Jan 22-29;289(4):450-3

Comparison of Energy Densities

Prentice AM et al Obes Rev. 2003 Nov;4(4):187-94

10 week-followup

● sucrose; mean BMI 28.0; n=21

∆ artificial sweetners; mean BMI 27.6; n=20

Over study period, significant differences

between changes in:

body weight- P < 0.001

fat mass- P < 0.05

At different time points:

* P < 0.05

** P < 0.001

*** P < 0.0001

Mean SEM

Changes in body weight, fat mass and fat-free

mass in overweight people during

intervention with sucrose vs. artificial

sweeteners.

Raben A, et al. Am J Clin Nutr 2002;76:721-9.

„Energy-density“of typical fast-food

A.M. Prentice et al. Obes Rev. 2003;4:187-194

145% more energy

per meal compared

with a traditional

African diet

Summary:

Energy density

• Energy content of fast food is

+145% higher of Gambian traditional food

• Energy density correlates best with fat content

• No adaptation process

• PASSIVE over-consumption

• Results in:

– Higher fat intake

– Weight gain

Case 1

Male, 56 y

Sales representative

„lots of business lunches“

BW: 93.4; FM: 26.1 kg (28%); LBM: 67.3 kg

BMI: 32.3

~ 1000 km of cycling every month

Actual Medication:

-Diamicron (Gliclazidum): 0-0-1

-Glucophage 1000 (Metformin): 1-0-0

-Selipran (Pravastatin): ½-0-½

Case 1

Therapy:

1) Ketogenic diet (1200 kcal/d) for 6 wk

1) 200 g of meat/fish/poultry/(tofu)

2) Vegetable side dish

3) salad

2) Slight reduction of endurance activities

3) Adaptation of diabetic medication according to

blood glucose

WM male 56 years

60

65

70

75

80

85

90

95

10

.05

.01

20

.05

.01

30

.05

.01

09

.06

.01

19

.06

.01

29

.06

.01

09

.07

.01

19

.07

.01

29

.07

.01

08

.08

.01

18

.08

.01

28

.08

.01

07

.09

.01

17

.09

.01

27

.09

.01

07

.10

.01

17

.10

.01

27

.10

.01

06

.11

.01

16

.11

.01

26

.11

.01

06

.12

.01

03

.01

.02

13

.01

.02

23

.01

.02

02

.02

.02

12

.02

.02

22

.02

.02

KG

0

2

4

6

8

10

12

14

16

KG

Blutz.

Ketogenic Diet1) Definition:

• The KD is both a high-fat/low-non-fat diet, and a diet that is

calorie-restricted

• Any diet providing nutritional or body fat for the generation of

ketones that serve as an alternative fuel to body tissues may

be called “ketogenic”

2) Side effects• Usually none to only slight side effects if carried out properly

- hyperuricemia

- gout

- gallstones

3) Indication• Weight reduction under medical supervision and normal

metabolic status- age < 60 y

- BMI ≥ 30 kg/m2

Ketogenic Diet• Contraindications:

• Absolute:

- Low serum potassium

- Hyperuricemia

- Any form of renal dysfunction

- Nephrolithiasis

- Instable angina

- Myocardial infarction within the last 6 months

- Epilepsy

- Pregnancy and lactation

- Malignancies

• Relative

- certain professions

• Drivers

• Pilots

• etc.

- Eating disorders

Ketogenic Diet: Procedure

1) Thorough clinical examination:• Exclusion of contraindications

2) Evaluation of protein need• Rule of thumb: per 10 kg of target weight 10 g of protein

(may be increased)

3) Patient instruction• Basic principles

• Permitted and not permitted food

• Preparation techniques (fat- and CHO-restricted cooking)

• Possibly self control with ketone sticks

• Slow resumption of CHO after diet

4) Regular weight control in your office

5) Transition phase

Ketogenic Diet: food choice

1) Protein need based on target weight:• 10 g of biological valuable protein per 10 kg of target weight

- Dairy products

300 ml: skim milk, buttermilk, whey protein drinks

2 x 180 yogurt (preferentially skim milk yogurt)

100 g cottage cheese, tofu

50 g of 50% fat cheese

- Eggs

1 egg

- Fish

60 g of fish (any kind, preferentially lean types) or

canned fish in water

- Meat

- 50 g of lean meat (pork, beef, veal, horse, poultry,

venison)

- 30 g of dried meat

Ketogenic Diet: food choice

2) In addition to the protein a vegetable side dish for the

main course is allowed. A total of two servings per day

are allowed. They may be taken from either group.• Vegetable group 1 (1 serving = 200 g)

- Eggplant, artichoke, broccoli, cauliflower, cucumber, salt

cucumber, pepperoni, cabbage (all types), mushrooms, radish,

spinach, asparagus, tomato, chicory, onions, zucchini, celery,

fennel

• Vegetable group 2 (1 serving = 150 g)- Green beans, green lattice, dandelion, carrots, pumpkin

3) One green salad per main course is extra

WM male 56 years

60

65

70

75

80

85

90

95

10

.05

.01

06

.06

.01

03

.07

.01

30

.07

.01

26

.08

.01

22

.09

.01

19

.10

.01

15

.11

.01

12

.12

.01

26

.01

.02

22

.02

.02

21

.03

.02

20

.04

.02

21

.05

.02

18

.06

.02

16

.07

.02

14

.08

.02

10

.09

.02

11

.10

.02

07

.11

.02

11

.12

.02

07

.01

.03

03

.02

.03

02

.03

.03

29

.03

.03

25

.04

.03

26

.05

.03

24

.06

.03

21

.07

.03

22

.08

.03

25

.09

.03

KG

0

2

4

6

8

10

12

14

16

KG

Blutz.

Severe illness of close

family member

Herniated

disc

impedes

physical

activity

FAT EATER

Nutritional Fat

Typical nutrition

composition

Recommended nutrition

composition

Fat 40%

Protein15-20%

Protein15-20%

CHO

40-50% Fat 30%CHO

45-55%

Case 2

Femal, 58 y

Yoga instructor

„can’t move my body properly anymore“

BW: 86.9; FM: 38.2 kg (44%); LBM: 48.7 kg

BMI: 31.9

~ apart from Yoga no other physical activity

Actual Medication:

-HRT

Case 2

Low-fat Diet1) Definition:

• Any diet with a restriction of fat may be called a low-fat diet.

• Mostly a low-fat diet will also have some sort of fat-

modification.

2) Side effects• Usually none if fat restriction is not absolute

3) Indication• A modified composition of fat should be part of every healthy

nutrition. It may play a special role in- Cardiovascular disease (Mediterranean diet, PUFA-rich diets,

DASH-diet, etc) for the prevention/therapy of dyslipidemia, and

the primary and secondary prevention of arteriosclerosis

4) Contraindications:• None. Basically a fat-modified diet may be carried out at any

time without side effects or hazards to the health, as long as

the fat restriction is not too harsh (HDL-Cholesterol may

decrease, and cancer risk increase) and a healthy mix of

nutrition is maintained

Low-fat Diet: Procedure

1) Thorough clinical examination:• Evaluation of cardiovascular risk factors

• Blood lipids

• Blood pressure

2) Diet modification• Reduction of fat below 30% of total energy intake (max. 60-

70 g fat/d)

• Distribution of fat-types: SFA:MUFA:PUFA=<1:1-1.5:<1

• Cholesterol < 300 mg/d

• Avoid/reduce trans fatty acids

• Increase of fibers to ≥ 30 g/d

• Diet should be high in CHO (~ 55-60% of total energy intake)

• Avoid alcohol or strict alcohol reduction

3) Regular weight control in your office

4) Well suited as lifelong diet

Low-fat Diet: food choice

• Ask your dietitian!

„Fat-Quiz“

Recognize and estimate hidden fat!

Would you have know it?

9 g of fat0,7 g of fat

12 g of fat 1,3 g of fat

1 handful = 40 g 1 handful = 50 g

2 g of fat 7 g of fat

1 handful = 40 g 1 handful = 20 g

10 g of fat 32 g of fat

1 plate 1 Pizza

0,4 g of fat 32 g of fat

1 seving (side dish) = 60 g 1 serving = 180 g

26 g of fat 2,4 g of fat

1 sausage = 110 g 1 chicken breast = 150 g

Low-fat Diet: medical treatment

Active

center

lipase

Stable Xenical-complex blocks fat digestion

OH

CHONH

H2NCO

OH

Xenical®

42

Xenical prevents the absorption of up to

30% of dietary fat...

…which pass through the body

undigested and are excreted.

30% of

triglycerides

pass

undigested and are excreted.

Consistent weight loss in clinical trials

6.1%6.6%

5.8%

10.2%9.7%

8.8%

0

2

4

6

8

10

12

Sjöström Rössner Davidson

Weight loss (%)

p<0.001p<0.001p<0.001

Placebo + diet

Xenical + diet

Sjöström L et al Lancet. 1998 Jul 18;352(9123):167-72

Rössner S et al Obes Res. 2000 Jan;8(1):49-61

Davidson MH et al JAMA. 1999 Jan 20;281(3):235-42

Xenical: Long-term weight reduction

Sjöström L et al Lancet. 1998 Jul 18;352(9123):167-72

Verä

nd

eru

ng

Kö

rperg

ew

ich

t (%

)

-4-10

-8

-6

-4

-2

0

0 10

PlaceboXenical® 60mgXenical® 120mg*p<0.01

20 30 40 60 70 80 90 10452

Xenical: XENDOS-results

Torgerson JS et al Diabetes Care. 2004 Jan;27(1):155-61

–4,1 kg

–6,9 kg

p<0.001 vs. Placebo

0 52 104 156 208–12

–9

–6

–3

0

Placebo +

lifestyle modification

Xenical +

lifestyle modification

Woche

(kg)

Low-fat Diet

Weight loss after 15 mts of low-fat diet and Xenical

86.9

82.8

79.377.6

74.7

71.4 71.372.3

60

65

70

75

80

85

90

06.05 08.05 10.05 01.06 03.06 05.06 07.06 09.06

kg