Diet and Exercise

Todd Sontag, DO Oviedo, FL How Huge of a problem is

• 35% of adults are obese – 48% of Non-Hispanic Blacks – 42% of Hispanics – 33% Non-Hispanic Whites – 11% Non-Hispanic Asians – 40% of among middle age adults (40-59) – No state had a prevalence of less than 20% – 70% of adults are overweight or obese Obesity Prevalence 2014 Importance of Weight Loss

• Obesity raises risk of diabetes by 10-20 times – Rates of diabetes up 60% over last 10 years • High Blood Pressure – 10kg : 3mmHg Systolic/2.3mmHg Diastolic • Dyslipidemia • Coronary Heart Disease, MI, Heart Failure Medical Weight gain

• Hypothyroidism • Cushing’s syndrome • PCOS • Pregnancy • Medications – Corticosteroids, antidepressants, antiepileptic drugs, diabetic medications • Lack of sleep, anger, stress Myths

• Eat several small a day to keep metabolism high to lose weight • Skipping a slows down your metabolism • It’s as simple as calories in and calories out!

Meal Frequency and Metabolism

• There is no difference between eating the same amount of food ranging from 1-17 meals a day in terms of 24 hour energy expenditure. • Another study out of University of Ontario: 3 meals verses 3 meals plus 3 snacks – same amount of food – no statistical difference in weight loss, fat loss or muscle loss • May help control cravings, pains but people tend to eat too much over day the more meals they eat I can’t lose weight because…

• I don’t have time to workout • I travel a lot and live out of a hotel • Healthy food is too expensive • I don’t have time to cook • Diets make me hungry • I’ve always been overweight • It’s my genetics • Something is wrong with my thyroid • My metabolism is slow • I’m not fat, I’m big boned What to believe?

• Fats are bad. Fats are good. There are good fats and bad fats. • Carbs are bad. Carbs are good. There are good carbs and bad carbs. • You should eat more meals. You should eat less meals. • Count your calories. Don’t count your calories.

What to Believe

• 2 articles released 5 days apart – May 5, 2016 BMJ: Slimmest people had the lowest risk of dying over a 15-year period. Obese men and women had the highest risk. • Same journal: gaining weight over time linked with higher risk of premature death – May 10, 2016 JAMA: Risk of dying early for any reason is now the same among obese individuals as normal-weight individuals • BMI 27 was linked to the lowest risk of death from all causes. Accountability

• American Journal of Preventative Medicine – Most powerful predictor of weight loss directly related to food journal days • Highest success related to those that shared their journal with someone else Dietary Guidelines

• Originally issued in 1977 by politician George McGovern: Less fat/more carbohydrates – Carbohydrates: 60% of calories • Over the next 20 years: – Fat intake decreased, butter consumption decreased, animal protein decreased, egg consumption decreased – Grains and sugars increased – Obesity dramatically increased from about 15-30%

Genetics

• Obese adults have obese children • Obese children have obese siblings • Obese children become obese adults – 200-400% increased risk • Genetics or environment?? – Obesity became a major problem after the 1970’s

American Heart Association

• 1995: An Eating Plan for Healthy Americans – 6 or more servings of breads, cereals, pasta and starchy vegetables that are low in fat and cholesterol – Fruit punch, carbonated soft drinks Let’s talk about Fat

• All fats are not created equal • Does saturated fat intake increase risk of heart disease? – No relation between dietary fat and blood cholesterol – No correlation between saturated fat intake and CHD • No association between dietary fat and obesity • Saturated fats and monounsaturated fats (olive oil) had the least strokes – Polyunsaturated fats (vegetable oil) had no effect Fats

• Eating fat does not make you fat • Eating fat tends to decrease glucose and insulin spikes • Women’s Health Initiative Dietary Modification Trial – 50,000 low fat vs regular diets – Low fat, calorie-restricted diet produced no benefits in weight loss. No reduction in cancer, heart disease or stroke. Insulin

• Higher insulin associated with higher body fat mass • Diabetics given insulin with a reduction of calories still gained weight • Diabetic medications- drugs that raise insulin cause weight gain, drugs that lower insulin cause weight loss – Effect is independent of their effect on glucose levels • If insulin levels are lowered, does this result in weight loss? Insulin Index

• Food Insulin Index – Directly quantifies postprandial insulin response – Measures blood insulin response compared to a reference glucose (FII=100) – Dependent on carbohydrate, quantity and quality of protein and fat and their interactions – Glycemic index is not always proportional to Insulin response FII

• Highest – Jelly beans (120), pancakes (112), honeydew melon (95), potatoes (90), breakfast cereals (70- 113) • Lowest – Olive oil (3), avocado (5), walnuts (6), tuna (16), chicken (20) FII

• Direct association between higher FII foods consumed and obesity and triglyceride measurements • Inverse relationship between higher consumption of high FII foods and HDL among the obese Cortisol

• Prolonged cortisol raises glucose levels which then raise insulin levels – Results in weight gain • Prednisone is a synthetic cortisol – chronic elevation causes weight gain • What causes chronic elevation of cortisol naturally? – Stress (physical or mental)

Cortisol and Obesity

• Elevated cortisol cause obesity? – Cushing’s syndrome • Patients gain weight regardless of amount of food/exercise – Cortisol-excretion rates correlated to BMI and waist circumference (non-cushing’s) • Higher cortisol levels in heavier people • Higher urinary cortisol have higher waist to hip ratios • Poor sleep causes elevated cortisol levels

Cortisol and Obesity

• Reduced cortisol and weight loss – Addison’s Disease • Supplements to block cortisol – Don’t work!! Strategy: Calorie Counting

• Eat less and workout more! • MyFitnessPal, LoseIt! – MFP use showed no long term weight loss • 500 calorie deficit to lose a pound a week • First calculate the BMR – Gender, age, weight, height and level of activity Set Point Theory

• Is it as Simple as a calorie deficit?? • Are Calories In and Out independent of each other? – Studies are showing the answer is No • Decreasing Calories In triggers a decrease in Calories Out • Are all Calories equal? – Do we get the same metabolic response from a calorie from an avocado versus a calorie from a candy bar? • No Set Point Theory

• Body fat percentage and body weight are matters of internal controls that are set differently in different people • There is a control system built into every person dictating how much fat they should carry • Long term caloric deprivation acts as a signal for the body to turn down its metabolic rate – Calories are burned more slowly – becomes progressively less effective – Results in the plateau

So Why do we Gain Weight?

• National Health and Examination Survey: 1990-2010: no association between increased calorie consumption and weight gain – Obesity increased at a rate of 0.37% per year – Men: decreased calories 2616-2511 – Women: slight increased 1761-1781 The British Equivalence

• Neither increased caloric intake nor dietary fat correlated to obesity • Calorie ingestion slightly decreased even as obesity rates increased. Strategy: Low Carb

• Atkins, South Beach • Carbs increase insulin which prevent fat breakdown • Atkins: ketosis phase with increasing total carbs • SB: Good carbs/Bad Carbs based on glycemic index Strategy: Ketosis

• Significant limitation in carbs to enter ketosis • Improves your ability to burn fats as an energy source. • Pros – Lowers insulin levels – Decreases appetite – Benefits epilepsy • Cons – Bad breath – Restrictive choices – Initial fatigue and brain fog – Stress on kidneys

Paleo

• Eat like a caveman • Reduces waist size and weight • Improves satiety Strategy: Low Fat

• Primarily plant based diet • Very low fat intake – about 10% or less • Commonly, these are high in sugars/carbs Strategy: Fasting

• Alternating fasting/non-fasting days – No decrease in metabolism – Typically consume less overall food over a week – Varies from a few hours from a missed meal to 24- 48 hours – Tend not to correct food selection or portion control Strategy: HCG

• The Weight Loss Cure They Don’t Want You to Know About – Cited for making false claims • of 500-800 cal/day – Short term weight loss – Weight loss is from severe calorie restriction, not HCG • No long term weight reduction or fat redistribution • Not FDA approved for weight loss

Strategy: Brands

• • Nutrisystem • Jenny Craig

Extreme Weight Loss

• Cotton Ball Diet • Feeding tube diet – Dieters fed a slow steady drip of protein and fat up to 800 calories a day and zero carbs • Tapeworm diet • Cleanses/Detox • • A plastic mesh is sewn onto the tongue Exercise

• What Kind? • How much? • Exercise without dietary change does not result in weight loss • 30-45 minutes/day, at least 5 days a week (ACSM) • Heart rate training – Initially 40-60% max, long term up to 75% – As fitness improves, exercise efficiency improves • Increase duration or intensity Exercise

• Interval training – Body gets more efficient when doing cardio exercise in “cruise control” – Short bursts in increased intensity have shown to significantly be more effective in body fat loss • International Journal of Obesity: – High-Intensity Interval Training vs Steady State Exercise » Significant reduction in total body mass, fat mass, trunk fat and fasting plasma insulin » Only the HIIE group displayed fat loss in legs Wearable Technology

• FitBit Apps

• MyFitnessPal, LoseIt! • Pokemon GO Therapy

• When combined with diet and exercise, produces better long term success Phentermine

• Short term – 12 weeks • Cheap • Effectiveness: 8lbs in 24 weeks Qsymia

• Phentermine/Topiramate – Birth defects

Contrave

• Naltrexone/bupropion • 5-8% weight loss • Improved A1c, Trigs, and HDL in diabetics • Lower depression Saxendra

• Higher dose of Victoza • 8% weight loss Orlistat

• Many side effects: oily stools, flatulence, anal leakage – 90% discontinue • Fat-absorption inhibitor • Recommended to be used in conjunction with a fat-restricted diet • Taking psyllium reduces GI side effects by about 40% • Available OTC Comparing pharmacological treatments • Meta-analysis of 28 randomized trials with almost 30,000 patients • Qsymia had 75% of patients achieve 5% weight loss at 52 weeks – 8.8kg • Saxendra - 63% - 5.3kg • Contrave - 55% - 5 kg • Belviq – 49% - 3.2kg • Orlistat – 44% - 2.6kg

• Jama June 14, 2016 Kybella

• For the “turkey neck” • Injected into subq fat – causes fat destruction • Approved for contouring the area under the chin What’s the Latest?

• AspireAssist – Surgically placed tube to drain a portion of stomach contents after every meal. • Pasta is good for weight loss! – Italian study funded by Barilla and the Italian government • Obalon – Ingestible and inflatable balloon • Obesity more deadly for men than women – 30% to 15% prior to age 70 What does Dr. Oz say?

• Chew Gum • Boost your metabolism with green tea or chili peppers • Eat red pepper flakes early to lower the amount of food you’ll eat later • Have sex instead of eating out What does Kim say?

• Atkins 40 diet – 3-4 6oz servings of protein – Fiber rich carbs – Healthy fats

Supplements

• ? – Ineffective with risk of rhabdomyolisis • HCG – Ineffective with risk of DVT, depression, cardiovascular • Garcinia cambogia – Conflicting results – no evidence of meaningful or sustained weight loss • Green Tea extract, coffee bean extract – Ineffective • Hoodia – No reliable evidence – Increased BP, heart rate, bilirubin and alk phos Supplements that are effective

My Recommendations

• Listen to your body – Eat when you’re hungry • Eat real foods • Meal plan • Look at nutrition prior to dining out • Find a plan that works for your lifestyle • Accountability is key! • For exercise – interval training is best • Medications/medical issues • Ignore Dr. Oz