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Helping People Make Healthy Lifestyle Changes: What Works, Why?

Hope S. Warshaw, MMSc, RD, CDE, BC-ADMOwner, Hope Warshaw Associates, LLC

Twitter: @HopeWarshaw facebook.com/EatHealthyLiveWell

17th Annual Montana Diabetes Professional ConferenceOctober 24, 2014

Presenters Disclosures*

• Food and nutrition clients:– McNeil Nutritionals, LLC (Splenda® Brand Sweeteners)

– Beneo Institute (dietary fibers)

• Diabetes clients: – Insulet Corporation

– Locemia Solutions, ULC

• Online weight management coaching:

– DPS Health

*As of 10/14

Program Goals

1. Detail clinical impact of weight loss/maintenance to prevent/delay progression preD, T2D with recent research evidence.

2. Identify factors for successful weight loss/maintenance from recent research evidence.

3. Through dialog with successful “losers” and HCP counselors/coaches challenge and/or reinforce HCP strategies, tools, and techniques to support clients’ weight management efforts.

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Time Program

10:00 – 11:00 am Presentation

11:00 – 11:45 am Panel discussion

11:45 am - noon Q & A and recap

BIG Applause to Montana!

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Diabetes Prevention Program Delivery in Montana• Adapted in 2008 for group‐based implementation and telehealth delivery to rural/frontier areas.

• Enrolled over 5,300 participants since 2008.

• Reimbursed by MT Medicaid in 2012 for Medicaid beneficiaries.

Table.  Outcomes at 4 months among participants in the Montana Diabetes Prevention Program, 2008‐2013.

All participants, 2008‐2012

(n=3,804)

Medicaid only, 2012‐2013

(n=118)

Mean (SD) Mean (SD)

Age (years)   52.5 (11.9) 46.7 (12.9)

Baseline BMI (kg/m2)   36.2 (7.2) 40.2 (9.7)

Number of core sessions attended       13.7 (3.8) 11.2 (4.8)

Weight change (kg) 2.3 (2.1) 3.0 (6.1)

% n % n

Sex (female) 82 (3,119) 74 (87)

Self‐monitoring fat intake  ≥14 weeks 16 (546) 47 (55)

Achieved 150 min physical activity per week 64 (2,072) 59 (70)

Achieved 7% weight loss  34 (1,300) 17 (20)

Data Source:  Diabetes Prevention Program, Montana, 2008‐2013.Data Notes:   Enrolled defined as attending at least one visit.  

Completed program defined as attending at least 4 core and 3 post core visits. 

Prediabetes to Type 2 = Progressive

Overweight Begets, Prediabetes & T2D

• Diabetes (US): – 29 mil1 (9%) (21 mil dx)

• ~95% T2

• ~85% T2 overweight

• Future glimpse– 40% of population, 2 out of 5 to develop in lifetime2

1. CDC, National Diabetes Statistics Report – 2014 http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf.2. Gregg EW, et al., Trends in lifetime risk and years of life lost due to diabetes in the USA, 1985—2011: a modelling study. Lancet

Diab and Endo. e-pub 8/13/14. http://www.thelancet.com/journals/landia/article/PIIS2213-8587(14)70161-5/fulltext

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Overweight Begets, Prediabetes & T2D

• Prediabetes (US)– 86 mil1, majority overweight

• 37% of adults >20 yr; 51% over 65 yrs1

• Only 11% aware2 ( from 8%3)

• Progression PreD to T2D: – 70% will develop T24

– Annually 11% preD not engaged in healthy lifestyle develop T2D following 3 yrs5

1. CDC, National Diabetes Statistics Report – 2014 http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf.2. Li Y, Geiss LS, Burrows NR, Rolka DB, Albright A, Awareness of Prediabetes:United States, 2005–2010. Morbidity and Mortality

Weekly. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6211a4.htm?s_cid=mm6211a4_w.3. Geiss LS. Diabetes risk reduction behaviors among U.S. adults with prediabetes. Am J Prev Med. 2010;38(4):403-409.4. Narayan KMV, et al. Lifetime risk for diabetes in US. JAMA. 2003;290:1884-1890. 5. Knowler WC, Barrett-Conner E, Fowler SE, et al; Diabetes Prevention Program Research Group. Reduction in the incidence of

type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393–403.

Detail clinical impact of weight loss/maintenance to prevent/delay progression preD, T2D with recent

research evidence.

Natural History: Wt Gain, Loss, Regain

Eckel RH et al: Obesity and type 2 diabetes: What can be unified and what needs to be individualized? Diabetes Care 34:1424-1430, 2011

Years YearsMonths

Prevention Therapeutic Space

Body Weight

Age-related Wt Gain

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Diabetes Prevention Program (DPP):Trial Basics1

• DPP initiated: 1998, stopped 2001

• RCT, multi-site in U.S.

– ~3000 subjects

• 4 arms to 3 arms: metformin w/ std care, placebo/stdcare, Intensive Lifestyle Intervention (ILI)

• Wt loss: 5 – 7% from initial

• Exercise: 150 min; 30 min, 5x/wk

• DPP Outcomes Study (DPPOS) extension, ongoing: Does further reduction in diabetes development reduce complications?

1. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403.

DPP/DPPOS Results to Date –Reduction of Incidence of T2D in

High Risk Population

ILI* Metformin/Std Care*

DPP1 58% 31%

DPPOS at 10 yrs2 34% 18%

DPPOS at 15 yrs3 27% 17%

1. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403.

2. Diabetes Prevention Program Research Group 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. The Lancet. 2009;374(9702):1677–1686.

3. American Diabetes Assoc. 2014 Scientific Sessions. Long-term follow-up of DPP show continued reduction in diabetes development. http://www.diabetes.org/newsroom/press-releases/2014/long-term-follow-up-of-diabetes-prevention-program-shows-reduction-in-diabetes-development.html

*Compared to placebo/std care. All DPP participants offered lifestyle intervention post DPP, leading to reduction in differences over time.3

DPP Lifestyle Changes: Weight Loss or Physical Activity?

• DPP Findings:– Weight loss = dominant predictor of

reduced T2 incidence and return to normoglycemia1

• For each kg weight loss = 16% reduction in risk for T22

• Subjects who lost > 5 – 7% reduced T2 risk > 90%2

– Physical activity helps sustains weight loss – plays “supporting role”

1. Perreault et al. Regression from pre-diabetes to normal glucose regulation in the DPP. Diabetes Care. 2009;32(9):1583-1588.2. Hamman, et al. Diabetes Care. 2008;29(9). 3. Delahanty L, Nathan D: Implications of the DPP and Look AHEAD clinical trials for lifestyle interventions. J Am Diet Assoc.

2008;108 (4 Suppl 1): S66-72.

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DPPOS – 15 yr F/U1

• Conclusions1: – Can prevent/delay T2D with ILI or metformin over long term

– Regardless of DPP treatment type, participants w/ out T2D at 15 yrshad 28% lower occurrence of microvascular disease

– Minimal incidence of CVD (HA, stroke) (young, healthy population)

– HTN improved in ILI, less in metformin DPP group

– Metformin: DPPOS largest, longest trial using drug, safe and well-tolerated; small increase in B-12 deficiency

• Summary: Weight loss key factor in preventing progression of prediabetes to type 2 and in restoring normoglycemia to some.2

1. American Diabetes Assoc. 2014 Scientific Sessions. Long-term follow-up of DPP show continued reduction in diabetes development. http://www.diabetes.org/newsroom/press-releases/2014/long-term-follow-up-of-diabetes-prevention-program-shows-reduction-in-diabetes-development.html

2. Diabetes Prevention Program Research Group 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. The Lancet. 2009;374(9702):1677–1686.

Look AHEAD Trial

• Study details: – Long term (start ~2000), multicenter, RCT,

study extended to 2014 (ended early 10/19/12)1,2

– > 5,137 (55-76 yrs), overwt or obese individuals2

– T2 diabetes for 6.8 + 6.5 yrs (range 3 mos – 13 yrs)3

– Median follow up 9.6 yrs4

• Primary Outcome: – Will intentional weight loss reduce the incidence of fatal and

nonfatal cardiovascular and cerebrovascular events?

1. http://www.nih.gov/news/health/oct2012/niddk-19.htm 2. Look AHEAD Research Group. Reduction in weight and cardiovascular disease risk factors in individuals with type 2

diabetes. Diabetes Care. 2007;30(6):1374-13833. Bertoni, et al. Journal of Diabetes and its Complications. 2008;22(1-9). 4. Look AHEAD Research Group. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J

Med 2013;369:145–154.

Look AHEAD Trial – Groups Defined• Intensive Lifestyle Intervention (ILI):1,2

– Goals: 7% or greater wt loss at one year, >175 minutes physical activity/week

– Calorie goal: 1200-1800 cals/day, < 30% of cals as fat, (<10% sat fat), minimum 15% cals as protein, use portion-controlled meals and meal replacements

– Support: • 0 – 6 mos: weekly (group and individiual)

• 6 mos – 1 yr: 3x/mos (group and individual)

• Remainder of trial: regular with decreasing frequency2

• Diabetes Support and Education (DSE)/(control):– Support: invite 3 group sessions/yr (not mixed)

– Standardized protocol for eating plan, physical activity, social support.

– No focus on behavioral strategies

1. Look AHEAD Research Group. Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes. Diabetes Care. 2007;30(6):1374-1383

2. Look AHEAD Research Group. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 2013;369:145–154.

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Look AHEAD: Changes in Weight1,2

Mean wt loss from baseline 8.6% ILI,

0.7% control1,2

1. Look AHEAD Research Group. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 2013;369:145–154.2. Delahanty L. The Look AHEAD Study: implications for clinical practice go beyond the headlines. J Acad Nutr Diet. 2014;114(4):537-542.

Mean wt loss from baseline 6% ILI, 3.5% control1,2

Look AHEAD – Positive Results, Despite Headlines1,2,3

• Median follow up 9.6 yrs1

• Mean wt loss from baseline 6% ILI, 3.5% control1

• A1c lowering ILI group 0.2%1

• Primary outcome: Failed to reduce CVD events in ILI vs. control

• Other health benefits: • Reduced sleep apnea, depression, urinary incontinence and improved QOL3

• Subjects with early stage disease = most health benefits• Shortest duration

• Not on insulin

• Good baseline glycemic control

1. Look AHEAD Research Group. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 2013;369:145–154.2. Delahanty L. The Look AHEAD Study: implications for clinical practice go beyond the headlines. J Acad Nutr Diet. 2014;114(4):537-542.3. Warshaw HS. The Look AHEAD Trial: Look beyond the headlines. Wt Mgmt Matters/WMDPG. 2014;12(4):2-3. Diab Care and Ed DPG

Newsflash. 2014;35(3):9-11.

Look AHEAD – Positive Results, Despite Headlines1,2

• Financial analysis2:– ILI produced mean relative per-person 10-year healthcare cost

savings of $5,280; not evident in ppl w/ hx of CVD

– Average annual savings ~$600/participant

– ILI used fewer medications (7%), had fewer hospitalizations (11%)

• Look AHEAD continues as observational trial

1. Look AHEAD Research Group. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 2013;369:145–154.2. Espeland MA, et al., Impact of an intensive lfestyle intervention on use and cost of medical services among overweight and obese adults with

T2D: (Look AHEAD). Diabetes Care. 2014;37:2548–2556.

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Weight Loss Matters Most – When?

But Healthy Eating is continuously important and can always assist

glucose, BP, lipid control!

ADA 2013 -Optimal Macronutrient Mix?1,2

• No one ideal % calories from carb, pro and fat for all

• No optimal mix to achieve wt loss• Wide variety of eating patterns shown modestly effective; all acceptable

to achieve positive metabolic outcomes

• Base mix around healthy eating goals, personal habits and metabolic goals

1. Evert A, Boucher J, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care: 2013;36(11):3821-3842.

2. Wheeler M, Dunbar S: Macronutrient, Food groups, and eating patterns in the management of diabetes. A systematic review of the literature, 2010. Diabetes Care. 2012;35;434-445.

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POUNDS LOST Study1

• Study details: – NIH - 2 yr wt loss trial, 800+ subjects, 2 sites– Overwt adults, BMI: 25 - 40– 4 diets, varying % calories:

• CHO - Low 35% to high of 65%

1. Sacks, F, et al. Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates. New Eng J Med. 2009;360(9):859-873.

POUNDS LOST Study1

Results:• No one nutrient composition faired better than another (subjects

modified towards diet goal, but didn’t reach diet’s goal)

• Weight loss: • 6 months: similar weight loss - 7% (6 kg/13 lbs) • 12 months: regained similar amounts of weight• 2 years weight loss remained similar: 4 kg/9 lbs • Subjects attending 2/3rd of sessions lost: 9 kg/20 lbs

• Clinical improvements: • Reduced cardiovascular disease and type 2 diabetes risk factors including

lower LDL-cholesterol, BG and serum insulin levels; and slightly lower BP

1. Sacks, F, et al. Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates. New Eng J Med. 2009;360(9):859-873.

ADA 2013 – Weight Management1

• Modest weight loss >6 kg (7-8.5%) may provide metabolic benefits (for some), esp early in disease

• Regular physical activity, and frequent contact with RDs (counseling/support) necessary for consistent, long term beneficial effects

• Reframe “success”:

– Minimize weight regain, maintain maximum of lost weight

– Prevent further weight gain, slow trajectory

1. Evert A, Boucher J, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care: 2013;36(11):3821-3842.

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Guidelines for the Management of Overweight and Obesity in Adults1

• Jointly published 2013: American Heart Association (AHA), American College of Cardiology (ACC), The Obesity Society (TOS)

• Part of update, integration of BP, cholesterol and obesity guidelines previously researched, disseminated through NHLBI

1. Jensen MD, et al. Guideline for the Management of Overweight and Obesity in Adults: A Report of the ACC, AHA, TOS Task Force on Practice Guidelines.Circulation. https://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437739.71477.ee.full.pdf+html?sid=6af28578-67b4-4bb1-9a4d-91ebab818a98 (published in 3 association journals)

2. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. Jour Am Med Assoc. 2012;307(5):491–507.

15 Dietary Approaches Associated

with Weight Loss by Expert Panel1

Among 15, range of options:* • Higher protein (25%), fat (30%), carbohydrate (45%)

• Lacto-ovo-vegetarian-style

• Low-fat (10% to 25% of total calories from fat) vegan-style

• Low-carbohydrate (initially <20 g/day carbohydrate)

• Mediterranean-style diet with prescribed energy restriction

• Provision of high-glycemic load or low-glycemic load meals

1. Jensen MD, et al. Guideline for the Management of Overweight and Obesity in Adults: A Report of the ACC, AHA, TOS Task Force on Practice Guidelines.Circulation. https://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437739.71477.ee.full.pdf+html?sid=6af28578-67b4-4bb1-9a4d-91ebab818a98 (published in 3 association journals)

*If reduction in dietary energy intake is achieved.

Weight Management or Do Nothing?

1. Hill JO, Wyatt HR, Reed GW, Peters JC. Obesity and the environment: Where do we go from here? Science. 2003; 299:853-855.

2. Knowler WC, Barrett-Conner E, Fowler SE, et al; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393–403.

Average American adult gains 1 to 2 pounds per year.1 If a person at the end of 2, 5 or 10 years (eg DPPOS, Look AHEAD) is at a lower body weight than they were at when they began their weight loss efforts, have they avoided gaining those 1 to 2 pounds per year and the health consequences? Gained potential health benefits?

From: Martin, C: WMDPG Symposium, April 2013

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BG-Lowering Meds: New Choices Can Support Wt Loss

• Start BG lowering meds (for most) at dx of T2 (e.g., metformin)

• Goal: treat insulin resistance1,2

– Choose meds to support wt loss/wt neutral vs. those can cause wt gain, stimulate hunger, cause hypo/eat

• Reframe PWD-T2 mindset on meds

– Not “diet failure,” it’s beta cell failure

– Meds work concert to treat progression of disease, newer ones can prevent wt gain, assist w/ wt loss

1. Position Statement American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD): Management of HyperglycemiainType2 Diabetes: A Patient-Centered Approach. Diabetes Care. 2012;35:1364-1379.

2. AACE. AADE comprehensive diabetes management algorithm 2013. Endocrine Practice. 2013;19(2):327-336. 31

BG Lowering Meds while reinforcing importance of,

strategies and support for weight loss/control,

healthy eating

STOP! START/PROGRESS

Identify factors for successful weight loss/maintenance from

recent research evidence.

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National Weight Control Registry (NWCR) - 10 years

• History: Initiated 1993, Wing and Hill

• Goal: ID successful wt loss maintainers and describe strategies to achieve

• Criteria: > 30lbs maintained > 1 yr; now > 10,000

• 10 yr study: enrolled 1993 – 2000

• Total: 2886 completed > 2 of 10 annual f/u surveys

• Wt loss: – Initial: 31.3 kg, keeping off 6.2 yrs

– 5 yr: 23.8 kg/77% of wt loss

– 10 yr: 23.1 kg/74% of wt loss

1. Graham Thomas J et al: Weight-loss maintenance for 10 yrs in NWCR. Am J Prev Med. 2014;46(1):17-23.

• Magnitude of initial wt loss and duration

• Increased physical activity

• Low calorie and low fat intake

• High restraint and low disinhibition around food

• Self-weighing > several times/wk

1. Graham Thomas J et al: Weight-loss maintenance for 10 yrs in NWCR. Am J Prev Med. 2014;46(1):17-23.

NWCR - 10 yearsPredictors of Success

“Continued adherence to each behavior can improve long term outcomes.”

Weight Loss: Successful Strategies

• Ready, willing and able?1,2

• Focus, don’t overwhelm1,2

• Choose behaviors most ready to change1,2

• Reduce total fat to < 30% fat (don’t focus on carb)2,3

• Use of meal replacements/structure3

• Include physical activity2-5

• Early success (wt loss) predicts later success (frequent contact early)5,6

1. Bissett. Lessons from the DPP, On the Cutting Edge, Diabetes Care and Education. 2008;29(4). 2. Delahanty L, Nathan D. J Am Diet Assoc.1 2008;108(Suppl1):S66-72. 3. Wadden TA, et al. The Look AHEAD Research Group): One-year weight losses in the Look AHEAD study: Factors associated with success. Obesity. 2009;17(4):713-722. 4.Wadden, TA, Neiberg, RH, Wing, RR, et al., The Look AHEAD Research Group (2011), Four-Year Weight Losses in the Look AHEAD Study: Factors Associated With Long-Term Success. Obesity. 2011;19:1987–1998. 5. Look AHEAD Research Group. Eight-year weight losses with an ILI: The Look AHEAD Study. Obesity 2014;22(1):5-13. 6. Graham Thomas J et al: Weight-loss maintenance for 10 yrs in NWCR. Am J Prev Med. 2014;46(1):17-23.

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Weight Maintenance: Successful Strategies

• Physiologic realities1

– Lower calorie needs to maintain lower weight: 300 – 400/day

• Food/Calories:– Low calorie, low fat intake2,3,4, eat breakfast2,5

– Simplify eating plan, minimize choices3

• Physical Activity4: – Regular significant physical activity (60-90 min/day)2,4

– Minimize sedentary behavior eg TV watching5

• Maintain continuous support• Relapse prevention plan• Regular self weigh-ins4,5

1.Rosenbaum M: Weight Management DPG Symposium, 2013.2. Fletcher, On the Cutting Edge, Diabetes Care and Education. 2008;29(4). 3. Wadden, TA, Neiberg, RH, Wing, RR, et al., The Look AHEAD Research Group (2011), Four-Year Weight Losses in the Look AHEAD Study: Factors Associated With Long-Term Success. Obesity. 2011;19:1987–1998.4. Look AHEAD Research Group. Eight-year weight losses with an ILI: The Look AHEAD Study. Obesity 2014;22(1):5-13. 5. Graham Thomas J et al: Weight-loss maintenance for 10 yrs in NWCR. Am J Prev Med. 2014;46(1):17-23.

Panel Discussion

Recap Panel DiscussionTwo questions for you: 1. What were the most important points you

heard today?

2. What is one change you will make in your work with your overweight/at risk clients based on what you heard today?

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Themes - Success Stories PreD, T2D1

• Light bulb moments: – Hitting certain high weight

– Seeing photo of self/looking unhealthy

– Observing health consequences, dx preD, T2D

Warshaw, HS. Diabetic Living magazine. Eat to Beat Diabetes Bookazine 2015. (In press)

Themes - Success Stories PreD, T2D1

• Kick start into action/tools:– Program/facility for assistance

– Accountability to self, group members

– Using food scale

– Decrease restaurant eating, time spent in kitchen

– Less regular soda, use diet beverages, water, etc.

– Make exercise regular part of life, vary it

• Challenges: Life’s hurdles!

Warshaw, HS. Diabetic Living magazine. Eat to Beat Diabetes Bookazine 2015. (In press)

Themes - Success Stories PreD, T2D1

• Words of wisdom: – “Don’t beat yourself up if you ‘mess up’, get right back on track.”

– “Believe in yourself.” “Develop self-confidence.”

– “Be willing to take the first step, experience success, then another.”

– “Just jump in, do something positive for yourself.”

– “Believe food that’s healthy for you can taste good too.”

– “Discover what motivates you long term.”

Warshaw, HS. Diabetic Living magazine. Eat to Beat Diabetes Bookazine 2015. (In press)

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In Summary

Arya Sharma, MD, Keynote: AADE 2013:• Obesity/overweight a chronic, progressive condition

• Early, aggressive management is critical

• It’s not a treat it, you’re done condition

• Our goal should NOT be to help people get thinner, but to help people get healthier. Take the attention off of weight.

• “I only care about the weight you can keep off.”

AADE 2013, http://www.presentdiabetes.com/ezines/#ezine413.Chair in Obesity Research and Management at the University of Alberta in Edmonton and Director of the Alberta Health Services Obesity Program. http://www.drsharma.ca/. Twitter: @drsharma.

In Summary

B.J. Fogg, PhD, Keynote: AADE 2013:• Fogg equation: BC (behavior change) =

M (motivation) + A (ability to make the change) + T (the trigger).

– Tie new behavior to existing, easier to accomplish

• Build “success momentum” - make one tiny habit change after another

• Can’t break bad habits thinking if you break it once, it will be fixed. We can, overtime, “untangle” bad habits

• Behavior change mastery occurs due to continual practice. Eventually “healthy reflexes” emerge

• “Help people change what they already want to change, not what they know they should change but don’t really want to.”

AADE 2013, http://www.presentdiabetes.com/ezines/#ezine413. BJ Fogg is a professor at Stanford University in California, where he runs the Persuasive Technology Lab. http://www.bjfogg.com/. Twitter: @bjfogg.

Reads and Resources• The conscienhealth blog: http://conscienhealth.org/. Daily blog capturing latest

obesity research and puts in perspective with links to research.

• David Allison/UAB weekly recap/e-mail Obesity & Energetic Offerings. Recap of latest publications/articles on hot obesity topics. Link to subscribe: http://www.obesityandenergetics.org/subscribe

• David Katz, MD: (regular blogs)

• diatribe: monthly e-newsletter from Close Concerns: subscribe at diatribe.us

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Thank You!!!