Robert Karp, MD

SUNY Downstate Medical Center

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PRE-TEST

Q1. Pick best answer. The most effective diet for sustaining weight loss is:

A. A very low in fat, high carbohydrate and protein contents

B. A restrictive in carbohydrate intake with little or no restrictions on fat and carbohydrate

C. Modest in fat reduction while mixing all three macro- nutrients in daily intake

D. No data is available to say that any one of the three choices is better than another.

Q2. Which of the following choices is a part of behavior modification

A. Limiting the size of the plates used at home

B. Never eating foods containing high fat content

C. Drinking diet sodas rather than sugared ones

D. Not eating breakfast

Q3. Which of the following activities burns 100 calories for a 60 to 70 kg person:

A. Walking one mile

B. Jogging one mile

C. Swimming 1/5 of a mile

D. They all burn 100 calories

Q4. True or false? A person who gains 10 kg from 60 kg to 70 kg will have a lower metabolic rate than that of a person who maintained a weight of 70 kg.

Q5. True or False? A person who intentionally loses weight from 70 kg to 60 kg will decrease their metabolic rate so that it is lower than that of a person who has maintained a weight of 60 kg.

Q6. True or False? Losing weight is effective in decreasing a patient's cost-of-living.

OBJECTIVES

On completion of this module, residents and physicians will be able to describe the characteristics of “successful losers” - obese adults who have been able to become lean and remain so for five years. These include:

1. The socioeconomic characteristics associated with success and failure

2. The possibility for change after a singular event

3. The sensibility and simplicity of the dietary regimen used by successful losers

4. The use of behavior modification techniques

5. The substantial amount of physical activity required to maintain body weight without continued dieting and

6. The need for resources providing exercise aids.

FACILITATOR PREPARATION

In 1997, ML. Klem published a study based on a commutative record of almost 200 people who had successfully lost weight and held it off for five years or more. - Subsequently, Klem’s and his colleagues have examined the characteristics of successful losers. In doing so, these researchers have prepared a body of research on what strategies are effective in helping adults lose weight and maintain that loss. This module is based on their work.

See the original paper: Klem ML, Wing RR, McGuire MT, Seagle HM, Hill JO. A descriptive study of individuals successful at long-term maintenance of substantial weight loss. Am J Clin Nutr. 1997;66:239-46.

And a recent reprise: Wing RR. Phelan S. Long-term weight loss maintenance. American Journal of Clinical Nutrition. 2005;82(1 Sup):222S-225S.

Also see Leonard H. Epstein, Michelle D. Myers, Hollie A. Raynor, and Brian E. Saelens. Treatment of Pediatric Obesity. Pediatrics. 1998;101(supp:554-570s

Hassink S. Problems in childhood obesity. Prim Care. 2003 Jun;30(2):357-74.

Dietz WH, Robinson TN Overweight children and adolescents. N Engl J Med. 2005 May 19;352(20):2100-9.

Authoritative chapters on obesity in childhood are by William Dietz are (in) Shils ME, Modern Nutrition in health and Disease 9th and 10th editions, (1999 and 2006. See also the chapter by Dr. Dietz in Pediatric nutrition..(2003) Alan Walker (ed) BC Decker, Publishers. The chapter on adult obesity treatments by Drs Wadden , Byrne, and Krauthammer-Ewing was helpful in appreciating the nuances of behavior therapy. Helpful aids in writing this module were

1. Laurel Mellin’s Shapedown, Balboa Press San Francisco, CA. (1983) Dr. Mellin has written several other works available through booksellers.. Her ShapedownTM program has been sold as a proprietary program with her name no longer attached. Source material can be obtained by a web search for ShapedownTM".

2. “Learn” from Kelly Brownell, Ph.D. The most recent version is The LEARN Program for Weight Management 2000, published by American Health Publishing Company of Dallas, Texas, and Distributed by LEARN-The LifeStyle Company (call 1-888-LEARN-41 to order).

INTRODUCTION

Writing in 1997, Klem and colleagues provided data collected by the National weight Control Registry on 629 women and 155 men who had been identified as obese and were successful in achieving weight loss and holding their lean(er) status for at least five years. In 2004 their work was updated in a review by Wing and Phelan. A PubMed or Ovid search will bring out more specific information on the body of their research. See above (I think it is often easier for people to get recent articles on ovid or e-journals from their institution than book chapters).

Almost nothing had been written with a positive outcome prior to the Klem et al article. Earlier works had suggested that the chance of successful weight loss by an obese adult ranged 2 to 5 %. Why was this? Much of the data collected was from individuals not engaged in a committed program for weight reduction. Data taken from an unselected pool of casual losers would not bear positive results nor would assessments of individuals who expect to go from obese to lean. Assessments from a review of diabetics, where the expectations were tied to diabetes control rather than weight, pre se, show that 37% of individuals were able to lose and sustain a loss of 7% of weight. Wing and Phelan suggest that 20% of obese persons actually lose and sustain at this level. Their definition of a “successful losers” is “individuals who have intentionally lost 10% of body weight and kept it off for one year.” Much of the health benefit of weight reduction come at this level.

What does it take to lose and sustain? The Table below provides a summary of the study’s findings. The module that follows provides discussion and supportive material.

TABLE 1. Characteristics of “successful losers”

TEACHING CAPTION: Up to number six, it would seem that success at losing was certain for a well-motivated and reasonably affluent person. Wing and Phelan report that our Successful Losers find it easier to sustain weight loss than to lose weight.

We will consider each of the elements of this table. Success or failure in weight reduction depends on mastery of each.

CASE STUDY

Deborah M is a 20 year old junior in college. Her father is an accountant, and her mother is a teacher. Both have been modestly over weight throughout life. Deborah’s birth weight was 3,200 grams. Her mother had gestational diabetes controlled by diet and she was recently diagnosed as having Type 2 DM. This is still controlled by diet. Her father has had a history of hypertension and is now on beta blocker medication. As can be seen in her growth curves, below, Deborah experienced acceleration in weight gain in the two periods of adiposity gain – Adiposity Rebound and Preadolescence.

FIGURE 1A. – A Growth curve showing weight gain through infancy as modest

TEACHING CAPTION: It is a mater of current debate as to the importance of prenatal undernutrition or post natal rapid weight gain as the principal early risk factor affecting likelihood of adult onset Metabolic Syndrome.

FIGURE 1B. - growth curve showing weight rising above 95th at 5 years of age and sustaining itself at that level through adolescence. Height is at 95th also

FIGURE 1C. A BMI Curve showing an early AR and following the 90%ile

The Case Continues

These past few weeks, Deborah was feeling rather sluggish, and she went to the student health. The physician took a history including a careful assessment of her diet. She found that Deborah would periodically go on diets. Both low and high carbohydrate diets were successful for a short time, but they were followed by weight gain to above where she started. She did not, however, have any history that suggested bulimia – no purging or laxative use, for example.

Her weight was recorded at 192 pounds [87.2 kg]and her height at 66 inches [1.68 m]. The BMI was calculated at 31kg/m2. The physician did not measure Deborah’s waist and hips, but she did note that the distribution was more “apple” than “pear.” Her BP was 136/85. The physical examination was otherwise unremarkable except for some deepening shadows at the neckline. The physician drew blood for studies.

Q1. What tests would you order here?

A1. The history suggests that Deborah has incipient Type II Diabetes Mellitus. A fasting lipid profile, blood sugar, insulin and a Hemoglobin A1C level in the blood should be obtained as well as urinalyses with a check for microalbinuria. One should, however, wait to evaluate the hypertension to see if it continues or resolves on two visits one to two weeks apart. Most physicians would order a two-hour glucose tolerance test with insulin levels immediately along with the Hgb A1C and the urine check.

The laboratory results show Deborah’s fasting glucose was 95 mg/dL with an insulin level of 27.0 ÌU/mL. The ratio of insulin to glucose in absolute numbers was greater than 0.14 and is abnormal. Her Hgb A1C of 7.2% is just above limit of 7.0%. There was no sugar in the urine sample, nor was there microalbuminuria. A level greater than 30 gm would be excessive.

The glucose tolerance curve shows a 1-hour postprandial sugar level of 150 gm/dL and the two-hour level 116. The 2-hour insulin level remained high at 34 ÌU/mL. These findings represent ”chemical diabetes,” e.g., impaired glucose tolerance. All urine sugars are negative.

At this point, most physicians would begin intensive intervention. Deborah chose to use diet and exercise as treatment rather than beginning a course of metformin. This oral hypoglycemic agent has been shown to provide islet cell sparing with delay in onset of clinical diabetes mellitus.

Q2. And what would you suggest for Deborah to do?

Here’s an opportunity for role playing. Remember, it is at the first crises that a highly motivated person can initiate the changes that they know they should. Deborah’s overweight, latent DM, and hypertension are now a reality.

A2. The need for change will be emphasized. Here is a listing of what is necessary.

An appropriate diet has a diversity of foods. It is not overly restrictive for either fat or carbohydrates. The fat content of a sustainable, effective diet provides about 25% of total calories. Be sure to have breakfast.

1. Behavior Modification - Much attention must be paid to the how and when of shopping and eating.

2. The importance of exercise – 1: the need to burn 400 calories a day with physical activity. Waking may be the simplest way to burn calories, but more exercise with supervision may be needed

3. The importance of exercise - 2: use or resources at the student gym or at home. Some facilities provide a trainer for individual with a fee or a gym supervisor gratis. Some very overweight individuals may not feel comfortable exercising in public, and home equipment is helpful in that case.

The Case continues

You, the physician, offer this advice, arrange for follow-up and a glucose tolerance test. [Deborah is on campus so it’s rather easy for her to show up at the Student Health fasting]

This suggests chemical diabetes with elevation in blood sugar at peak and two hours post prandial without spilling glucose in the urine

Figure 2. – a GTT curve – abnormal superimposed on a normal one

CAPTION: this is a classic curve for chemical diabetes without sufficient elevation to produce glycosuria

Q3. And what would you suggest for Deborah to do?

A3. Here’s an opportunity for role-play. Remember, it is at the first crises that a highly motivated person can initiate the changes that they know they should. Deborah’s overweight, latent DM, and hypertension are now a reality

The need for change will be emphasized. Here is a listing of what is necessary.

An appropriate diet has a diversity of foods. It is not overly restrictive for wither fat or carbohydrates. The fat content of a sustainable, effective diet provides about 25% of total calories. Be sure to have breakfast

1. Behavior Modification - Much attention must be paid to the how and when of shopping and eating

2. The importance of exercise – 1: the need to burn 400 calories a day with physical activity. Waking may be the simplest way to burn calories, but more exercise with supervision may be needed

Q4: What are appropriate diet changes for a healthy 20 year old seeking to reduce weight and sustain that loss?

Here are some principles: Suggest a diet that has about 25% as fat, 4 or 5 servings of fruit and the same for vegetables, 2-3 servings of low-fat dairy products, and an emphasis on whole grain foods. Meats, pasta, rice, potatoes, and condiments continue to be used in moderation. Beans can be used in place of meat or as a vegetable serving. [Hyperlink to hypertension] This diet is modeled on the Dietary Approach to Stop Hypertension (DASH). There is a relatively low glycemic Index for these foods taken together. Material on the DASH diet can be obtained at www.nhlbi.nih.gov/health/public/heart/hbp/dash/

Q4a. What do you mean by “glycemic index?

A4a. As shown in Figure 3, the Glycemic Index (GI) is a ratio calculated from the area under the glucose tolerance curve of a standard 50-gram glucose challenge (the denominator) and a similar curve formed from the consumption of a specific food (the numerator).

Figure 3. – Glycemic Index Curve

CAPTION: The area under the Glucose Tolerance Test curve for Glucose itself forms the Denominator. The Numerator is the area under the GTT curve for a specific food in question

Potatoes, for example, contain quickly absorbed starch. The area under the blood glucose vs. time curve for potatoes contains almost the same area as a standard glucose tolerance curve. Thus, the Glycemic Index is high for potatoes. By contrast, meals containing wheat bran tend to have slowly absorbed sugar, less area under the blood glucose curve, and a low GI. Recent studies by Ludwig and colleagues provide data suggesting that a freely chosen low GI diet is more effective in promoting and sustaining weight loss in obese children than controlled low calorie dieting. Recently, bran cereal meals (low GI) taken in the morning were found to promote less food intake at lunch without regard to nutritional status of the children. In this study, children found high GI breakfasts more palatable on the first days of the study but not thereafter suggesting the importance of resolve in offering nutritious food. [See the review by David Ludwig, “Glycemic load comes of age” in J Nutr. 2003 Sep;133(9):2695-6.

Q4b. How are behavior modifications applied?

A4b. Here is a chance to go over with residence the principles of Behavior modification. These will include:

1. Making reasonable goals so that any steps taken will be seen as success rather than failure

2. Being aware that this is an obesogenic environment and what is seen as normal behavior will lead to increased weight in an at-risk individual.

3. Carefully planning of when, where, and how one shops, cooks, eats, and cleans up after eating.

4. Using positive reinforcement principles by rewarding oneself in new ways unassociated with weight loss or gain. Here’s what Laurel Mellin suggests. Instead of food, “reward yourself with a bunch of daisies, a special magazine, a bright ed blouse, or a new tape [CD]. Rewarding yourself with non-foods is a THIN HABIT. You are treating yourself well…So liberally reward yourself with non-food rewards.” p134.

Let each resident give an example of how he or she has experienced the obesogenic environment and what he or she did.

My own personal experience was having to replace my plates at home with larger ones. That is, we were told that the 9-inch diameter dinner plates were no longer available. We had to buy 10 1/2-inch diameter ones. Working out the increase in flat food surface size from 3.5-inch radius to 4.25 inch radius (Br2 for each) gives an increase from 38.5 sq in to 56.7 sq in. This represents a 147% increase in surface area. We solved the problem a year so later by fining “Luncheon Plates” in the same pattern. There are 9 inches across. The first week or so of eating off of the new plates we felt that we were eating off doll’s dishes.

Q5. Why do you suggest a diet with modest reductions? Aren’t high fat and protein diets effective in promoting weight loss?

A5. The high fat, high protein diets [often given the name “Atkins” after the physician who popularized these regimes] initiate the ketosis associated with semi-starvation.

With continued caloric deprivation, the body mobilizes fat, attempts to preserve protein, and reduces appetite. Hunger is a characteristic of short-term deprivation. The chronically starved person loses appetite. He or she is not particularly hungry. The Atkins’ Diet, at least as Atkins described it, violates the first law of thermodynamics –– the law of energy conservation ––

FIGURE 4. The First Law of Thermodynamics describes the conservation of energy

TEACHING CAPTION: W is energy expenditure. It depends on the Basal Metabolic Rate plus expenditures related to disease states plus expenditures with activity. These vary among individuals with the same body mass. Q comes from what is consumed. When Q is greater than W, the excess energy is stored as fat. When Q is less than W, energy is lost, e.g., there is weight loss. It’s just that simple, but weight loss affects metabolism and does increase efficiency.

The importance of modest exercise – “Lifestyle Change”

Another element of importance in promoting life style change is that the control of appetite seems to have a lag of about 300 calories a day before appetite increases. As the figure below shows, one can add to energy expenditures with lifestyle changes and not increase energy intake to the same level

FIGURE 5. Modest Energy Expenditure DOES NOT Increase Energy Intake.

The Y axis is “Energy Added = Q.” The X axis is “Energy Expended = W.”

Teaching Caption: The energy expenditure achieved through increased everyday activity or moderate amounts of vigorous exercise [W~300 calories] will not be offset by an increased appetite and energy intake [Q]. This will produce a slow reduction in “U,” the energy stored. Weight loss will occur.

High fat, carbohydrate depleted diets

These particular diets propose to counter the increased efficiency of metabolism associated with weight loss by a creating ketosis similar to that of starvation. Appetite is lost and with it body weight.

The major problem with these diets is that they are not sustained. A diet of lobster tails in butter plus steak and eggs, and more becomes unpalatable. The followers of Atkins, the most recent proponent of these diets, simply lose their appetite. As shown in module #6 in this section [Hyperlink to Genetics X Environment], a starvation diet of this sort results in a metabolic rate falling below the expected required for body mass. Resumption of a normal diet with little or no change in behavior or exercise patters creates a perfect opportunity for weight gain above starting level.

In fairness to those struggling with obesity, there are those individuals for whom this regimen has been successful. Personal experience, unsubstantiated by data, is that these successful individuals have adopted much of the behavior modification and exercise of the “successful losers” described by Klem, Wing, and Phelan.

Q6. Fat restricted diets are not included here. Why not?

A6. High carbohydrate diets have been suggested as a means to reverse coronary atherosclerosis. Dr. Dean Ornish has documented some successes when the objective is diminishing coronary atherosclerosis rather than obesity, per se. [see Ornish D, et al. Intensive life style changes for reversal of coronary heart disease. JAMA 1998;280:2001-7.] That is, opening of coronary vessels has been demonstrated for some patients with coronary heart disease. The full regimen includes meditation and relaxation techniques to counter the commonly found “Type A” behavior of these patients. There are exercise and behavior modification elements in the regimen. The carbohydrates in Dr. Ornish’s regimen are predominantly whole grains rather than of a Western “white bread” vegetarianism.

On a practical level, however, this regimen is difficult to maintain without a sword (extant disease) over ones head. Hunger is likely and frequent feedings necessary. For the most part, food cultures of the United States have not supported a vegetarian pattern that is satisfying. One exception, the Seventh Day Adventist community, does provide an assortment of meat substitutes. Vegetarian diets of and for themselves are not found. This may change as our society becomes more diverse and tasty healthful foods are brought from the Mediterranean, Caribbean, Africa, and Asia. Of note, some patients have carbohydrate sensitive hyperlipidemia, and this diet is not appropriate for them. Dr. Ornish has a perceptive comment

“The debate should not focus only on low carbohydrate versus low fat. Patients have a spectrum of dietary choices. To the degree that they reduce their intake if refined carbohydrates and excessive fats and increase their intake of unrefined carbohydrates (fruits, vegetables, whole grains, legumes) and sufficient omega 3 fatty acids, they may feel better, lose weight, and gain health.” (See 2004 Nov 2;141:738)

For all of these diets, support from and supervision by a Registered Dietician (RD) supervision is a necessity.

The case continues

Deborah returns for another visit. She feels better with her weight reduced to 180 pounds, and she likes her diet. Her BMI is now 29kg.m2. Deborah is pleased and wants to continue, but she is having difficulty finding a place and time to exercise. “I’m too busy to go out. I don’t feel safe either?” What might she do? You suggest that she use the facilities at the Student Center.

Q7. What advantage is there to use of exercise machines?

A7. Principles: One of the findings of the “Successful Losers” studies was that these people were able to add to the caloric expenditures of every day life plus conscious exercise by use of machines. At the time of the original study, the Stairmaster TM was most popular. There is no impact on the knees or ankles with these machines. Elliptical cycle machines seem to have replaced the StairMaster in gyms and homes. Treadmills providing elevation are also popular.

Use of facilities offers a chance to be a part of a community of “successful losers” who provide support for each other.

A 60 kg person walking on a treadmill set at 12-degree elevation and a speed of 4.3 miles per hour (a brisk walking gait) uses 15 cal/minute. With warm up and cool down there is a 200-calorie expenditure in 20 minutes. Add in a walk of a mile one way and a second mile for return, a 60 kg person will complete the 400-calorie requirement.

Again, there is a socioeconomic advantage for those with sufficient income, time, affiliation with an institution having a gym or pool, and living in a safe community. My own yearly expenditures include $110 for membership in the Student Center at SUNY-Downstate (gym and pool), $200 for a spouse membership to use the facilities at the university where my wife works (also a gym and use of two pools), $40 for a senior’s membership at the town pool, $200 for 2 new pairs of running shoes a year, another $200 to keep my bicycle in good repair, and another $90 to rent a bike locker to keep my bike at the local train station. This works out to a yearly expense of $840, and I can go out running at 3:00 in the morning.

Q8. Which form of guidance has a better chance of long-term success: Introducing intensive exercise or promoting general life-style changes?

A8. A set of studies conduced by Leonard Epstein and colleagues in Pittsburgh suggest that both intensive exercise and lifestyle change options are effective as a part of initial weight loss programs for adolescents. Long-term success is more likely with lifestyle changes. This includes walking when one could use a car or elevator or just sit. Limiting television, computer, or other screen time.” Gardening, house keeping and other activities with seemingly minimal energy expenditure do add up in the course of a day. [see Epstein LH, Meyers MD, Raynor R, Saelens BE. Treatment of Pediatric Obesity. Pediatrics. 1998;101 supp:554-570s]

Effective therapy will require attention to what the patient wants and is able to do. Most obese teens and all obese adults are deconditioned from years of sedentary life style. Their body fat is equivalent to carrying a very heavy pack. Lack of fitness, says Wadden, is a better predictor of over-all morbidity and mortality, per se. Ideally one would bring the fitness level of weight-losing teens and young adults from being able to walk less than a mile a day up to 4 miles a day. This will take about an hour when walked by a fit individual.

As noted above, energy expenditure achieved through increased everyday activity or moderate amounts of vigorous exercise [W] will not be offset by an increased appetite and energy intake [Q]. Rather, a slow weight loss and regain of fitness will ensue.

Q9. What are appropriate goals for Deborah?

A9. Again let residents discuss these

1. Promote self-confidence. Guidance should be based on health on health considerations rather than on perceptions of beauty. A sustained weight loss of 10% will have a profound affect on risk for the elements of the Dysmetabolic Syndrome.

2. Continue the weight loss and fitness program with a reasonable goal. There is no evidence that a BMI of 26 kg/m2 with a gynecoid distribution is associated with illness. One must be very careful not to trigger an eating disorder [Hyperlink to eating disorders] The body weight for a 66 inch tall woman to reach a BMI of 26 kg/m2 would be [____]. Let the residents guess the answer of 159 pounds.

3. Promote healthy eating through better food choices and behavior modification. Some of the food choice and behavior modification program would be institutional. That is what nutritious foods in your institution or neighborhood are available at reasonable cost and convenience?

4. Promote increased activity and exercise. “Lifestyle” is maintained better than “intensive exercise.” Encourage an “Up one; down two” policy for stairs vrs elevators. Keep exercise machines in places where residents and other workers could use them. Turn off all TV’s when left on. Emphasize safety in communities.

SUMMARY

We have presented a young woman with a strong family history of overweight and associated disorders. The success or failure of her future efforts to control weight depends on getting the right kind of guidance when she is ready to receive it. The success rate for control may be low for the population at large, but the response of the “Deborahs” –– highly motivated, well educated, and financial secure youth –– are actually quite good so long as the goal is a reasonable one. We must avoid doing harm and would be doing the Deborahs no service if we trigger bulimia, anorexia or “yo-yo” dieting as a substitute for overweight.

ANNOTATED ANSWERS

A1. The answer is C. Read on to find that the two most popular diets (restricting either “carbs” or fat alone) are less likely to achieve long term success. Modest reduction in fat content to 25% of calories in the context of a fixed diet gives the best long-term results. Simple sugar consumption however is restricted.

A2. The answer is A. It is behavior modification. The supersizing of plates is one part of the obesity epidemic. Choosing to use smaller (e.g., what most adults knew as regulars) 9 inch rather than 10 inch diameter plates reduces servings by about 30%.

A3. The answer is D. Whether one walks or runs a mile, the caloric expenditure is still 100 calories. It just takes longer to burn the 100 kcal walking. Swimming a mile requires about 500 calories.

A4. The answer is False. There is an adjustment in caloric need to long-term weight. The metabolism of the person who has gained weight speeds so that they are likely to lose weight unless they maintain extra intake or decrease activity. I think you could even make this simpler to understand. There is a natural pull back to the original weight. A person who is 60 kg but lost from 70 kg originally needs to eat fewer calories just to maintain weight than a person who started at 60 kg.

A5. The answer is True. The person who has lost weight is likely to gain unless they maintain a caloric deprivation or increase expenditure. The increase/decrease is about 400 kcal a day I think you could even make this simpler to understand. There is a natural pull back to the original weight. A person who is 60 kg but lost from 70 kg originally needs to eat fewer calories just to maintain weight than a person who started at 60 kg.

A6. This is a False statement even if it seems to contradict common sense. Consuming less calories and increasing exercise costs more? That can’t be! In fact, the cost of foods low in caloric density and high in micronutrients is substantially higher than the costs of calorie dense foods. There are also elements in the social environments common to poverty that make increased exercise and reduced calorie intake less likely.