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Preoperative Nutrition Management of Sleep and the RDN: Incorporating Sleep Bariatric Surgery Patients Education to Reduce Chronic Disease Risk militaryfamilieslearningnetwork.org/event/52258 March 18, 2020

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2 Exploring the Research on Fad Diets

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This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, and the Office of Military Family Readiness Policy, U.S. Department of Defense under Award Numbers 2015-48770-24368 and 2019-48770-30366. Today’s Presenter

Laura Andromalos, MS, RD, CSOWM, CDE Nutrition Program Manager Northwest Weight and Wellness Center Everett, WA

• Certified Diabetes Educator Coach in the telehealth setting for Cecelia Health • Has specialized in the field of weight management for over 10 years

5 Objectives

• List redeeming qualities and potential risks of popular diets • Identify fact-based sources for reviewing nutrition trends • Develop evidence-based nutrition interventions that incorporate patient preferences

6 Which diets do you get asked about most often?

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7 Agenda • Fad Diets – Ketogenic – Paleolithic – Intermittent – Low-Carb, High-Protein • Evidence-Based Interventions for Weight Management • Resources for Staying Updated Developing Nutrition Interventions

Each person and situation is inherently unique, which is why one-size-fits-all diets consistently fail

You need to address one's lifestyle challenges, personalize a plan that reflects your specific and unique goals, and understand which of the many barriers — behavioral, psychological and physical — need to be overcome.

Dr. Kushner So, what’s the point….

…. of learning about fad diets?

• Most self-directed diet attempts will be popular diets. We need to speak the same language as our patients. • We can learn from them. • They might be valuable stepping stones towards sustainability. KETOGENIC DIETS Ketogenic Diet Origins • Early 1920s – first trials with ketogenic diet as a treatment for epilepsy in children – Mimics the sensation of starvation for the brain

• Formula: – 1 g of protein per kilogram of body weight in children – 10–15 g of carbohydrates per day – Remainder of the calories in fat

Wheless 2008 Original Keto Diet 2000 calories Protein: 1 gram per kilogram = 23 grams = 92 calories

Carbohydrate: 15 grams = 60 calories

50 pounds = Fat: 22.72 kilograms 1848 calories = 205 grams fat The Demise of Keto

• Phenytoin became treatment of choice in 1938

• Less interest in ketogenic diet…. – led to fewer dietitians being trained….. – led to fewer people following the diet correctly…. – led to belief that ketogenic diet was not effective

Wheless 2008 Typical Energy Pathway

Eat carbohydrates

Carbs get broken down into glucose

Glucose gets linked together as glycogen

Glycogen gets stored in liver and muscle

Brain & body break down glycogen stores for energy Carb-Restricted Energy Pathway

Don’t eat carbohydrates

Body uses up glycogen stores in 3-4 days

Fat becomes primary source of fuel

Liver produces ketone bodies as a byproduct of fat breakdown

Brain uses ketone bodies for energy; body uses energy from amino & fatty acids Diapedia.org The Research

• 83 men & women with obesity • 24 week ketogenic diet with 30 g carb, 1 g/kg protein, 20% saturated fat, 80% poly & mono

Dashti et al. 2004 The Research

• 29 men & women with type 2 diabetes • Low-carb (20-50 g) keto (LCK) vs moderate-carb (165 g), low-fat, calorie-restricted (MCCR)

LCK group lost 8.3% weight. MCCR group lost 3.8% weight.

Saslow et al. 2017 Pros & Cons

Pros Satiety Evidence-based for epilepsy in children Glycemic management

Cons Keto flu Adjusting to extreme carbohydrate restriction Possible electrolyte & nutrient deficiencies Gut health Increased risk for dehydration, gout, kidney stones, osteoporois Not sustainable for most people A Day of Keto • 2 egg omelet with 1 ounce feta, ½ cup mushrooms, ½ cup spinach cooked in 1 Breakfast teaspoon butter • Coffee with 1 tablespoon cream • Salad with 1 cup lettuce, 1 ounce turkey, 1 ounce cheddar cheese, 2 slices bacon, ½ Lunch avocado, 10 cherry tomatoes, 1 tablespoon olive oil, vinegar • 3 ounces ground chicken cooked in 2 teaspoons olive oil, ½ cup zucchini Dinner noodles, ½ cup low-carb tomato sauce, ¼ cup parmesan cheese

Snack • ¼ cup almonds Promote healthy fats! Daily Total

25 grams net carb (7%) 44 grams total (13%)

71 grams 107 grams fat protein (21%) (70%)

1370 calories Checking Ketone Levels

Urine testing • Dip a strip into urine sample. More sensitive when first starting keto diet; with time, body adapts Blood testing • Finger stick, similar to testing for blood sugar. Most accurate for beta-hydroxybutryate (BHB) Breath testing • Breathe into a breath monitor. Measures level of acetone which is typically linked with level of BHB in blood How do you feel about supporting patients who want to try a ketogenic diet?

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23 PALEOLITHIC DIETS Paleo Diet Origins

• Developed Evolutionary Discordance Hypothesis

• Estimated that hunger-gatherers consumed 35% kcal protein, 45% kcal carbohydrate, 20% fat – 65% vegetation, 35% meat

• Humans adapted to farming shifted to 90% vegetation, 10% meat. Had shorter skeletons & signs of suboptimal nutrition Modern Paleo Diet

• Originally published in 2002, revised and popularized in 2010

• Excludes the starchy vegetation that played a role in the diet of hunter-gatherers

This Photo , Unknown Author, CC BY-NC-ND Cordain 2002, Cordain 2010 The Ground Rules

All the lean meats, fish, and seafood you can eat

All the fruits and non-starchy vegetables you can eat

No cereals

No legumes

No dairy products

No processed foods

Cordain 2002, Cordain 2010 Levels of the Paleo Diet

• Entry Level; 3 open meals Level I per week

• Maintenance Level; 2 open Level II meals per week

• Maximal Weight Loss Level; Level III 1 open meal per week

Cordain 2002, Cordain 2010 Additional Components

• No emphasis on calories and portions – Protein and fiber should provide satiety • Lean meats, ideally wild game, and unsaturated fats are encouraged • Water is the primary fluid • Supplement micronutrients as needed – Vitamin D, anti-oxidants, fish oil capsules (if not consuming fish)

Cordain 2002, Cordain 2010 The Research • 70 post-menopausal women with obesity • Paleo vs Nordic Nutrition Recommendations (NNR) – Paleo = 30% pro, 40% fat, 30% carb – NNR = 15% pro, 25-30% fat, 55-60% carb

Mellberg 2014 Spinoff: Whole 30

• Elimination Diet that excludes: – Sugar – Alcohol – Grains – Legumes – Dairy – MSG, carrageenan, sulfites Pros & Cons

Pros Cons • Satiating diet • Discourages consumption of • Encourages fruits and dairy, whole grains, and vegetables, omega-3 legumes fatty acids, and limited • Often inadequate in calcium processed foods and vitamin D • Limited calorie counting • Not feasible for and portion measuring vegetarians/vegans o But we need to create • Requires significant time for an energy deficit for meal preparation weight loss… A Day of Paleo • 2 egg omelet with mushrooms, onion, and Breakfast spinach cooked in 1 tsp oil • Orange • Salad with lettuce, cucumbers, tomatoes, 4 Lunch oz chicken, slivered almonds, 2 tsp olive oil & vinegar

• 4 oz salmon Dinner • Asparagus and broccoli

• 3 oz tuna with ¼ avocado and celery Snack sticks Daily Total

78 grams carb (22%)

119 grams 74 grams fat protein (48%) (34%)

1388 calories Versions of Intermittent Fasting

• Alternate between days of no restriction with Alternate Day days that provide about 25% of daily calorie Fasting needs. • 5-2 plan; 5 days normal eating, 2 days fasting

Whole Day • 1-2 days a week of complete fasting Fasting

Time- • Eating during a condensed time period Restricted • Example: eat from 8am-2pm; fast from 2pm to Feeding 8am The Research • Control Group: No intervention • Daily (DCR): 75% calories spread over three meals • Alternate-Day Fasting (ADF): 25% energy needs on fast days, 125% energy needs on feast days

Trepanowski et al. 2017 The Research

• No significant differences in blood pressure, fasting glucose, fasting insulin, total cholesterol, triglycerides. – ADF group had significant increase in LDL • Dropout rate was higher in the ADF group (38%) than in the DCR group (29%) • ADF group ate less food than prescribed on non-fasting days and more food than prescribed on fasting days

Trepanowski et al. 2017 The Research

When examining 12 clinical trials comparing fasting groups with continuous calorie restriction group, there was no significant difference in weight loss or body composition changes.

While intermittent fasting is certainly a strategy that works for some, as with any diet, the question a person need ask to determine if it's right for them is, "could I enjoy living this way forever," and if the answer's "no," then intermittent fasting isn't going to be their panacea.

Yoni Freedhoff, MD

Bachert 2018; Harvard School of Public Health The Research Calories early in day B: 700 calories L: 500 calories 93 women with D: 200 calories overweight/obesity Sedentary lifestyles; asked to keep baseline Calories late Randomized to a diet in day intervention for 12 weeks

B: 200 calories L: 500 calories D: 700 calories

Jakubowicz et al. 2013 The Research

Jakubowicz et al. 2013 Intermittent Fasting

Pros • Can be as effective as consistent calorie restriction • May have metabolic benefits • Time-restricted feeding may provide structure for people who eat late at night • Several variations so can be individualized

Cons • Not sustainable for many people • Not appropriate for all types of people (athletes, diabetes) • Research is still emerging What are your personal or patient experiences with intermittent fasting?

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43 LOW-CARB, HIGH-PROTEIN DIET The Definition

• Diets that have greater than 35% daily calories from protein • Most high-protein diets are actually low- carbohydrate diets – Atkins • First published 1972 – Protein Power Atkins Approach

• 4 phases progressing from 20g net Atkins 20 carbs to 100g net carbs • Most intensive plan

Atkins • 40g net carbs 40 • For weight loss goals <18 kg

Atkins • 100g net carbs 100 • For weight maintenance

atkins.com The Research • 245 individuals retained after 6 months • People with prediabetes lost more weight with focus on carbohydrate content

Astrup & Hjorth 2017 The Research

• 430+ participants followed low-carb or low-fat diet for 1 year • Started at 20 grams carb or fat; increased by 5-15 grams/week until sustainable – At 1 year, average 57 grams fat/day and 137 grams carb/day

Gardner et al. 2018 The Research

• No significant difference in 12-month weight loss. • Genotype not associated with weight loss Gardner et al. 2018 Pros & Cons

Pros • Satiety • Improvements in blood sugar & triglycerides • Multiple versions with varying level of carbohydrate restriction

Cons • Potential for ketosis symptoms • Lack of fiber & nutrients from whole grains and fruits • Challenging for vegetarians • Unknown effects of increased saturated fat consumption A Day of Atkins

Breakfast • 3 eggs scrambled, ½ tomato, ½ avocado

• Salad with 5 oz grilled chicken breast and Lunch 2 Tbsp Caesar dressing

• 5 oz grilled salmon, 1 cup arugula, ½ Dinner cup broccoli

• 1 string cheese Snack • 2 Tbsp almonds Daily Total

16 grams net carb 31 grams carb (9%) 116 grams 90 grams fat protein (57%) (34%)

1386 calories EVIDENCE-BASED INTERVENTIONS Is eating 5-6 times per day better than eating 2-3 times per day for weight loss?

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54 • A diet from the European Association for the Study of Diabetes Guidelines, which focuses on targeting food groups, rather than formal prescribed energy restriction while still achieving an energy deficit. • Higher protein (25% of total calories from protein, 30% of total calories from fat, 45% of total calories from carbohydrate) with provision of foods that realized energy deficit. • Higher protein Zone™-type diet (5 meals/day, each with 40% of total calories from carbohydrate, 30% of total calories from protein, 30% of total calories from fat) without formal prescribed energy restriction but realized energy deficit. • Lacto-ovo-vegetarian-style diet with prescribed energy restriction. • Low-calorie diet with prescribed energy restriction. • Low-carbohydrate (initially <20 g/day carbohydrate) diet without formal prescribed energy restrictionA varietybut realized energy of dietarydeficit. approaches can produce • Low-fat (10% to 25% of total calories from fat) vegan style diet without formal prescribed energy restriction but realized energy deficit. weight loss… • Low-fat (20% of total calories from fat) diet without formal prescribed energy restriction but realized energy deficit. • Low-glycemic load diet, either with formal prescribed energy restriction or without formal prescribed energy restriction but with realized energy deficit. • Lowerif reduction fat (≤30% fat), high in dairy dietary (4 servings/day) energy diets with orintake without increased is achieved. fiber and/or low- glycemic index/load foods (low-glycemic load) with prescribed energy restriction. • Macronutrient-targeted diets (15% or 25% of total calories from protein; 20% or 40% of total calories from fat; 35%, 45%, 55%, or 65% of total calories from carbohydrate) with prescribed energy restriction. • Mediterranean-style diet with prescribed energy restriction. • Moderate protein (12% of total calories from protein, 58% of total calories from carbohydrate, 30% of total calories from fat) with provision of foods that realized energy deficit. • Provision of high-glycemic load or low-glycemic load meals with prescribed energy restriction. • The AHA-style Step 1 diet (with prescribed energy restriction of 1,500–1,800 kcal/day, <30% of total calories from fat, <10% of total calories from saturated fat) Obesity is Heterogeneous

Used with permission from Scott Butsch, MD Variability in Response to Diets

12 month study completers Gardner 2012 Sustainability Matters!

“This supports the practice of recommending any diet that a patient will adhere to in order to lose weight.”

Johnston et al. 2014 “Ultimately, the best diet is the one the patient will follow and incorporate into his or her daily life for lifelong maintenance of a healthy body weight.”

Matarese & Pories 2014 Expected Outcomes Diet and exercise provide an average long-term (3-5 years) weight loss of about 3-5%. Bariatric surgery provides an average long-term weight loss of 20-30%.

Franz et al. 2007 Evidence-based Tools

Meal Replacement

Portion Control

Logging/Tracking

Academy of Nutrition & Dietetics 2018; Burke, Wang & Sevick 2011; Heymsfield et al. 2003 Putting it into Practice Meet your patient where they are What is motivating you to start a diet?

What do you like about this diet? What do you think would be most challenging?

What has worked well for you in the past? What derailed you?

What does success look like to you? STAYING UPDATED Publications • Position of the Academy of Nutrition and Dietetics: Interventions for the Treatment of Overweight and Obesity in Adults https://jandonline.org/article/S2212- 2672(15)01636-6/pdf

• 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults https://www.ahajournals.org/doi/full/10.1161/01.ci r.0000437739.71477.ee Web Resources The Nutrition Source – Harvard School of Public Health • https://www.hsph.harvard.edu/nutritionsource/healthy- weight/diet-reviews/

Nutrition and Dietetics SmartBrief emails • https://www.eatrightpro.org/membership/member- benefits/publications-and-subscriptions

Clinical Guide to Popular Diets • https://www.crcpress.com/Clinical-Guide-to-Popular- Diets/Apovian-Brouillard-Young/p/book/9781498774307 65 Summary • Any diet can lead to weight loss with energy deficit and sustainability • Evidence-based tools: – Meal replacements – Portion sizes – Self-monitoring • Dietitians need to be familiar with and open to all popular diets to customize nutrition plans to meet patients where they are References • Academy of Nutrition and Dietetics. Position of the Academy of Nutrition and Dietetics: Interventions for the Treatment of Overweight and Obesity in Adults. Journal of the Academy of Nutrition and Dietetics. 2016;116(1):129-147 • Academy of Nutrition and Dietetics Evidence Analysis Library. " In overweight/obese adults (aged 19+ years), what is the effect of consuming single serving portion sized meals on weight loss?" Accessed 22 January 2018: https://www.andeal.org/topic.cfm?menu=5311&cat=5386 • Astrup A & Hjorth MF. Low-fat or low-carb for weight loss? It depends on your glucose metabolism. E Bio Medicine. 2017;22:20-21. • Bachert A. Friday Feedback: Does Intermittent Fasting Have Merit? 2018, January 12. Medpage Today. • Burke LE, Wang J, and Sevick MA. Self-Monitoring in Weight Loss: A Systematic Review of the Literature. JADA. 2011;111(1):92-102. DOI: http://dx.doi.org/10.1016/j.jada.2010.10.008 References • Cordain L. The Paleo Diet. New York: Wiley; 2002. • Cordain L. The Paleo Diet: Lose Weight and Get Healthy by Eating the Foods You Were Designed to Eat. John Wiley & Sons; 2010 • Dashti HM, Mathew TC, Hussein T, et al. Long-term effects of a ketogenic diet in obese patients. Exp Clin Cardiol. 2004;9(3):200–205. • Eaton SB & Konner M. Paleolithic Nutrition — A Consideration of Its Nature and Current Implications. N Engl J Med. 1985;312:283-89 • Gardner CD, Trepanowski JF, Del Gobbo LC, et al. Effect of Low-Fat vs Low- Carbohydrate Diet on 12-Month Weight Loss in Overweight Adults and the Association With Genotype Pattern or Insulin Secretion: The DIETFITS Randomized Clinical Trial. JAMA. 2018;319(7):667–679. doi:10.1001/jama.2018.0245 • Harvard T.H. Chan School of Public Health. June 2018. Diet Review: Ketogenic Diet for Weight Loss https://www.hsph.harvard.edu/nutritionsource/healthy- weight/diet-reviews/ketogenic-diet/ References • Heymsfield SB, van Mierlo CA, van der Knaap HC, Heo M, and Frier HI. Weight management using a meal replacement strategy: meta and pooling analysis from six studies. Int J Obes Relat Metab Disord. 2003;27(5):537-49. • Hollis JF, Gullion CM, Stevens VJ, et al. Weight loss during the intensive intervention phase of the weight-loss maintenance trial. Am J Prev Med. 2008;35(2):118–126. doi:10.1016/j.amepre.2008.04.013 • Jakubowicz D, Barnea M, Wainstein J, and Froy O. (2013). High caloric intake at breakfast vs. dinner differentially influences weight loss of overweight and obese women. Obesity, 21(12):2504-2512 • Jensen MD, Ryan DH, Apovian CM, Ard JD, Comuzzie AG, Donato KA, Hu FB, Hubbard VS, Jakicic JM, Kushner RF, Loria CM, Millen BE, Nonas CA, Pi- Sunyer FX, Stevens J, Stevens VJ, Wadden TA, Wolfe BM and Yanovski SZ. AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation. 2013;01.cir.0000437739.71477.ee. • Johnston BC, Kanters S, Bandayrel K, Wu P, Naji F, Siemieniuk RA, Ball GDC, Busse JW, Thorlund K, Guyatt G, Jansen JP, and Mills EJ. Comparison of Weight Loss Among Named Diet Programs in Overweight and Obese AdultsA Meta-analysis. JAMA. 2014;312(9):923-933. References • Matarese, L and Pories, W. Diets: Adult Weight Loss Diets: Metabolic Effects and Outcomes. Nutr Clin Pract. 2014; 29:759-767 • Mellberg C, Sandberg S, Ryberg M, Eriksson M, Brage S, Larsson C. Olsson T, and Lindahl B. Long-term effects of a Palaeolithic-type diet in obese postmenopausal women: a 2-year randomized trial. • Randall R & Groveman S. The Ketogenic Diet for Epilepsy — Learn About the Diet, the Medical Conditions It's Used to Treat, and Its Mechanism of Action. Today's Dietitian. 2016;18(5):46 • Saslow LR, Daubenmier JJ, Moskowitz JT, et al. Twelve-month outcomes of a randomized trial of a moderate-carbohydrate versus very low-carbohydrate diet in overweight adults with type 2 diabetes mellitus or prediabetes. Nutr Diabetes. 2017;7(12):304. Published 2017 Dec 21. doi:10.1038/s41387-017-0006-9 • Trepanowski JF, Kroeger CM, Barnosky A, et al. Effect of Alternate-Day Fasting on Weight Loss, Weight Maintenance, and Cardioprotection Among Metabolically Healthy Obese Adults: A Randomized Clinical Trial. JAMA Intern Med. 2017;177(7):930–938. doi:10.1001/jamainternmed.2017.0936 • Wheless, James. 2008. History of the ketogenic diet. Epilepsia, 49(Suppl. 8):3–5 • Voegtlin WL. The Stone Age Diet. 1975;277 Questions?

Share your questions/answers with us in the chat pod! Laura Andromalos, MS, RD, CSOWM, CDE Email: [email protected] Twitter: @Landromalos Website: www.LauraAndromalos.com 71 Upcoming Event

Sleep and the RDN: Incorporating Sleep Education to Reduce Chronic Disease Risk

March 18, 2020 11:00 a.m. – 12:00 p.m. EST

Event Page: militaryfamilieslearningnetwork.org/event/56491/

This session will discuss how insufficient sleep increases the risk of chronic disease and makes the management of chronic conditions more difficult, and how dietitians can incorporate basic sleep education principles to help clients meet health goals.

Continuing education credit will be available for this webinar!

For archived and upcoming webinars visit: 72 MilitaryFamiliesLearningNetwork.org/AllEvents/ Evaluation & Continuing Education

This webinar has been approved Evaluation Link for the following continuing Go to the event page for education (CE) credits: evaluation and post-test link.

• 1.0 CPEU for Registered Dietitians

• A certificate of completion Questions? Email Kristen DiFilippo at [email protected]

Event Page: militaryfamilieslearningnetwork.org/event/52270

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