Diet and Exercise Todd Sontag, DO Oviedo, FL How Huge of a problem is Obesity • 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 Diet Myths • Eat several small meals a day to keep metabolism high to lose weight • Skipping a meal 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, hunger 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 fasting 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 – Dieting becomes progressively less effective – Results in the plateau So Why do we Gain Weight? • National Health and Nutrition 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 • Calorie Restriction 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 • Weight Watchers • 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 • Tongue patch diet • 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