10 November 2010 * Bangkok, Thailand ACD2010 · Public health officials worldwide are frustrated...

THE 5TH ASIAN CONGRESS OF DIETETICS

10 November 2010 * Bangkok, Thailand

The Key Role of Balance in the Development of Healthy Lifestyles

John P. Foreyt, Ph.D.Baylor College of Medicine

Houston, TXjforeyt@bcm.edu

ACD2010

The Key Role of Balance

• Public health officials worldwide are frustrated that consumers do not follow dietary guidelines to promote good health

• Private health practitioners and providers have similar frustrations

• Governments predict steep increases in the rates of chronic diseases, putting serious strains on the world’s healthcare systems and on national budgets

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Global Burden of Obesity

• 33% of the world's adult population now overweight or obese

• 23.2% overweight (24.0% men, 22.4% women) i.e., 937 million

• 9.8% obese (7.7% men, 11.9% women)i.e., 396 million

Kelly et al (2008) Intl J Obesity, 32, 1-7.

ACD2010

Global Burden of Obesity

• By year 2030, if secular trends continue unabated, 57.8% of the world's population will be overweight or obese (2.16 billion overweight, 1.12 billion obese.)

Kelly et al (2008) Intl J Obesity, 32, 1-7.

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All Calories Count:Prevalence (%) of Overweight (BMI > 25)

Among Adults

MALE FEMALE

THAILAND 28 40

UNITED STATES 71 62

who.int/infobase/ 2010

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The Key Role of BalancePrevalence (%) of Overweight (BMI > 25)

Among Adults

MALE FEMALEMYANMAR 32 47

INDONESIA 10 27

who.int/infobase/2010

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The Key Role of BalanceHealth Risks of Obesity

For every increase of 5 kg the relativerisk of:• CHD ↑ 14%• Stroke ↑ 4%• Ischemic Stroke ↑ 16%ACD2010

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The Key Role of BalancePrevalence of Overweight & Obesity

in U.S. Children & Adolescents (Ages 2-19)

• 33.6% Overweight• 17.1% Obese• Obesity has quadrupled over 25 years • African American, Hispanic American &

Native American children have highest obesity prevalence

Ogden, et al. 2009

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The Key Role of BalanceEstimates of Prevalence of Diabetes in

2000 & 2010 (in millions of cases)

2000 2010 Increase (%)Asia 84 132 57North America 14 17 23Europe 26 32 24South America 16 22 44Africa 9 14 50World Average 151 221 46

Eckel et al, Circulation 2004

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A Healthy Lifestyle is All About Balance:

Healthy DietHealthy Physical Activity

The Key Role of Balance

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The Key Role of Balance

UNFORTUNATELY…

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Big Texan Steak RanchAmarillo, Texas

72-oz Steak FREE if eaten within 1 hourACD2010

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AVERAGE ADULT AMERICAN MAN

Height: 5’ 9”Weight: 194 lbsWaist: 39.69 in.BMI: 28.4

McDowell, et al, NHS, 2008

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UNREALISTIC GOALS: AVERAGE FASHION MODEL VS AVERAGE WOMAN*

Height

Weight

BMI

5' 4"

153 lb

26.1

Average

Fashion Model

Average

Woman

5' 9"

110 lb

16.3ACD2010

Miss America, 2008

Kirsten Haglund

BMI: 16.29

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Luisel Ramos

Age: 22

Height: 5’ 9”

Weight: 98 lbs

BMI: 14.6ACD2010

Eliana Ramos

Age: 18

Height: 5’9”

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Ana Carolina Reston

Age: 21

Height: 5’ 8”

Weight: 88 lbs

BMI: 13.4ACD2010

29th OLYMPIADBEIJING, CHINA

• US wrestling team captain, Daniel Cormier (211.5 lbs), hospitalized for kidney failure as result of dehydration related to cutting weight (did not compete).

• US boxer, Gary Russell was found unconscious 4 days before his Olympic bout due to cutting weight (did not compete).

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29th OLYMPIADBEIJING, CHINA

Michael Phelps8 Gold Medals, Swimming

• Age: 23• Height: 6’4”• Weight: 195 lbs• BMI: 23.74• Daily Food Intake: 10,375 KCAL

(15% PRO, 58% CHO, 27% FAT)

• Exercise: 30 hrs/wkACD2010

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The Key Role of Balance

• Global concern regarding increase in obesity & obesity-related diseases

• Some critics have singled out sugar & sweetness as primary suspects for obesity & obesity-related diseasesACD2010

The Key Role of Balance

• Scientific evidence does not support “single culprit” theory

• The “culprit” is an excess of calories• There is a need to understand the

“calorie equation” • If calories in exceed calories burned

off, excess becomes body fat, & weight goes up

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The Key Role of Balance

• In studying diets of obese people, scientists have not determined that any specific food or beverage is the root cause of obesity

• A well-balanced diet is the key• All food and beverages can be a part

of a well-balanced dietACD2010

The Key Role of Balance

• In 2004, 2006, 2008 and 2009 scientists and researchers met to develop scientific consensus statements about sweetness & health

• They introduced the concept of managing sweetness to teach the calorie equation

• They encouraged consumers to incorporate it into their daily lives so they can enjoy the pleasures of the table, but to do so wisely

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The Key Role of Balance

• The 2004 conference was entitled “Scientific Straight Talk on Sweetness & Health: Managing Sweetness Conference”

• Organized by Oldways Preservation Trust, Boston, USA

• Held in Mexico City, MexicoACD2010

The Key Role of Balance

• In 2006, scientists and researchers met in Brussels, Belgium at the EU to update the scientific research on managing sweetness since 2004

• In 2007, Managing Sweetness Conferences were held with scientists in Brazil, Chile, Argentina and MexicoACD2010

The Key Role of Balance

• In 2008, and 2009 scientists and researchers met in Beijing, China, Istanbul, Turkey, and here in Bangkok, Thailand to update the scientific research on managing sweetness.ACD2010

The Key Role of BalanceConference Summary

• Research results indicate that individuals can incorporate sugars and sweeteners into a healthy eating plan and meet guidelines for healthful diets

• There is no credible evidence that total sugar intake is associated with the development of type 2 diabetesACD2010

The Key Role of BalanceConference Summary

• Children are born with a liking for sweet taste

• It is important for parents to learn to manage, not banish, sweet foods

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The Key Role of BalanceConference Summary

• Research suggests banishing favorite foods, like sweets, can lessen a child's ability to control intake of these foods when not under supervision

• Research has shown sugar in food and beverages does not cause hyperactivity in children

• All foods and beverages can be part of a healthy diet

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The Key Role of BalanceConference Summary

• Carbohydrates in food and beverage, including sparkling beverages, provide energy for daily activities

• There is no need to give up favorite foods• Consumption in moderation with an

active lifestyle is the key to weight management

• A balanced diet is the keyACD2010

The Key Role of Balance Conclusions

• Managing sweetness involves reconciling our innate taste preferences with the realities of our modern life and food supply

• All foods and beverages can be part of a healthy lifestyleACD2010

Comparison of Weight Loss Diets with Different Macronutrient

Compositions

Aim• To compare the effects of 4 diets of

differing macronutrient compositions on body weight after 2 years.

Sacks FM, et al. NEJM, 2009, 360, 859-873.

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Comparison of Weight Loss Diets with Different Macronutrient

Compositions• N: 811 overweight adults (BMI= 25-40)

randomized to diets with a deficiency of 750 kcal/day & addition of 90 min/wk exercise

• Outcome : Comparison of low fat (20%) vs. high fat (40%) & average PRO (15%) vs. high PRO (25%), & highest (65%) and lowest (35%) CHO

Sacks FM, et al. NEJM, 2009, 360, 859-873.

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Comparison of Weight Loss Diets with Different Macronutrient

Compositions - Results

• Reduced calorie diets result in meaningful weight loss regardless of which macronutrients they emphasize

• Attendance at group sessions strongly predicted weight loss at 2 years & was similar among the diet groups

Sacks FM, et al. NEJM, 2009, 360, 859-873.

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Comparison of Weight Loss Diets with Different Macronutrient

Compositions - Results

• Satiety, hunger, satisfaction with the diet & attendance at sessions were similar for all diets

• Behavioral factors (attendance, contact, commitment, engagement, etc.) rather than macronutrient metabolism were the main influences on weight loss

Sacks FM, et al. NEJM, 2009, 360, 859-873.

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Comparison of Weight Loss Diets with Different Macronutrient

Compositions - Results

• Any type of diet, when taught for the purpose of weight loss with enthusiasm & persistence, can be effective

• Macronutrient content is of minor importance

Sacks FM, et al. NEJM, 2009, 360, 859-873.

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Comparison of Weight Loss Diets with Different Macronutrient

Compositions - Results• Successful diets can emphasize a range of

fat, protein, & carbohydrate composition & have beneficial efforts on risk factors for CVD & diabetes

• Diets can be tailored on the basis of personal & cultural preferences and & therefore have the best chance for long-term success

Sacks FM, et al. NEJM, 2009, 360, 859-873

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COMPARATIVE DIETARY GUIDELINES

Carb% Fat% Protein %

Mediterranean Diet 45-55 25-35 20 NIH Dietary Ref. Intakes 45-65 25-35 15Am. Heart Assoc. 40-60 < 30 10-30NCEP-ATPIII 50-60 25-35 15Am. Diet Assoc. 45-65 25-35 15Food Guide Pyramid 60 30 15NCI, NIA, NIDDK, NHLBI 60 25 15Atkins Diet 11 56 33South Beach 36 43 22Zone Diet 40 30 30

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PARADOX OF INCREASING OBESITY PREVALENCE

• ↑ Focus on healthy eating and physical

activity

• ↑Awareness of dangers of obesity, but…

• Obesity prevalence continues to rise

• Work & commuting demands

• Little time to exercise

• Little time to prepare food

• Availability of high-fat/calorie foods

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READINESS TO CHANGE

“Habit is habit, and not to be flung outof the window, but coaxed downstairs a step at a time.”

Mark Twain

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BENEFITS OF MODEST WEIGHT LOSS

“Several studies demonstrate that small losses…help reduce obesity-related comorbidities and that improvements in these risk factors persist with maintenance of these modest weight losses.”

-Institute of Medicine, 1995

- ↓ Glucose levels - ↑ HDL cholesterol levels - ↓ Insulin levels - ↓ LDL cholesterol levels - ↓ Glycated hemoglobin - ↓ Blood pressure - ↓ Triglyceride levels - ↑ Quality of life levels

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REALISTIC MANAGEMENT GOALS

• 5-10% weight loss• Health, energy and fitness• Well-being and self-esteem• Mood and appearance• Functional and recreationalactivityACD2010

KEY ELEMENTS

• Focus on health and energy• Food and physical activity diaries• Gradual increase in physical activity• Gradual reduction in dietary fat• No feelings of food deprivation• Social support groupsACD2010

LookAHEAD• A twelve year, multicenter, randomized

clinical trial • To evaluate the health effects of

interventions designed to produce weight loss

• In 5,137 obese individuals with Type 2 diabetes ACD2010

Primary End Point Composite

• Cardiovascular death (including fatal myocardial infarction and stroke)

• Non-fatal myocardial infarction• Non-fatal stroke ACD2010

Winston-Salem

BaltimorePhiladelphia

New YorkProvidenceBoston

Clinical Site Coordinating Center

Clinical SitesSeattle

Los Angeles

San Antonio Houston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

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Recommendations

• Dietary Intake– 1200-1500 kcal/day < 250 lb– 1500-1800 kcal/day > 250 lb– < 30% calories from fat– Meal replacements– Menu plans provided

• Physical Activity– Gradual increases– 175 min/wk– 10,000 steps

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Participants

101100Baseline weight (kg)

58.958.6Age (years)

94%*96%Attended 1 year exam

36.035.9Baseline BMI15%14%Insulin Users

37%37%Minority60%59%Women

(N=2574)(N=2630)DSELifestyle

* p < .0004

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% Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p < 0.0001

% W

eigh

t Cha

nge

8.6%

0.7%

The Look AHEAD Research Group, Diabetes Care, 2007

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Look AHEAD Weight Loss Success Factors

At one year, the three significant weight loss success factors were:

• Self-reported physical activity (mean=137 minutes/wk)

• Treatment attendance (mean=35 sessions/yr)• Meal replacements (mean=361/yr)

Wadden, et.al. Obesity, 2009.

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1-Yr Weight Loss (ILI) Based on Quartiles of Weekly Physical Activity

11.9%

9.0%

4.4%

7.1%

02468

10121416

1st 2nd 3rd 4th

% R

educ

tion

in In

itial

Wei

ght

.

25.9 min 84.8min 148.7min 287.1 min

Look AHEAD Research Group. Obesity 2009;17:713-722.

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1-Yr Weight Loss (ILI) Based on Quartiles of % of Visits Attended

11%9.6%

4.6%

7.4%

0

2

4

6

8

10

12

14

1st 2nd 3rd 4th

% R

educ

tion

in In

itial

Wei

ght

.

51.3% 82.0% 92.5% 99.4%

Look AHEAD Research Group. Obesity 2009;17:713-722.

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1-Year Weight Loss (ILI) Based on Quartiles of Meal Replacements (MR) Used

11.2%9.4%

5.9%7.2%

0

2

4

6

8

10

12

14

1st 2nd 3rd 4th

% R

educ

tion

in In

itial

Wei

ght

.

117 277 406 608MRs MRs MRs MRs

Look AHEAD Research Group. Obesity 2009;17:713-722.

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Fitness Change (%) at 1-Year

0

5

10

15

20

25

Mea

n %

Fitn

ess

Cha

nge

Unadjusted P<0.001

Adjusted for 1 Year Weight Change P<0.001

5.8

20.9

10.8

15.9

DSE ILI ILIDSE

The Look AHEAD Research Group, Diabetes Care, 2007

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Mean Changes in Weight, Fitness & Blood Pressure

Averaged Over Four YearsDSE Mean

ILIMean

P-value

Weight Loss (% initial wt)

-0.88 -6.15 < 0.0001

Fitness (% METS)

1.96 12.74 <0.0001

HbA1c -0.09 -0.36 < 0.0001SBP (mm Hg) -2.97 -5.33 < 0.0001DBP (mm Hg) -2.48 -2.92 0.012

Look AHEAD Research Group, Arch Int Med, 2010

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Mean Changes in Lipid Profile Averaged Over Four Years

DSE Mean

ILIMean

P-value

HDL (mg/dl) 1.97 3.67 <0.0001TG (mg/dl) -19.75 -25.56 0.0006LDL (mg/dl) -12.84 -11.27 0.009LDL (mg/dl)(Adjusting for medication use)

-9.22 -8.75 0.42

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Percent (%) Completing Outcome Measures at Years 1-4

Intervention Group (ILI)

• Year 1 97.1• Year 2 94.9• Year 3 94.0• Year 4 94.1

Comparison Group (DSE)

• Year 1 95.7• Year 2 93.5• Year 3 93.8• Year 4 93.1ACD2010

Look AHEAD Summary

• ILI had significantly greater improvements than DSE in CVD risk factors averaged across 4 years

• There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

• Longer follow-ups will determine whether these lowered CVD risk factors can be maintained & whether lifestyle intervention has positive effects on CVD morbidity & mortality

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“The Current Epidemics of Chronic Diseases are a Result of Discordance

Between Our Ancient Genes and Modern Lifestyle.”

Eaton et al., The Paleolithic Prescription. 1988.

NATURE VS. NURTURE

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“Accuse not nature. She has done her part. Do Thou but Thine.”

John Milton (1687), Paradise Lost

NATURE VS. NURTURE

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The Key Role of Balance

Conclusıons• The achievement and maintenance of

good health depends on the wise management of the energy from all food and beverage sources, along with a habit of regular physical activity

• Sweet foods and beverages can compliment a balanced diet, regular physical activity, and other healthy lifestyle choices

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SECRETS OF SUCCESSFUL WEIGHT LOSS

Every Day:• Sleep 8 hours• Eat breakfast• Walk briskly 60 minutes • Write down what you eat• Weigh • Find support• Never give up

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The Key Role of Balance

Bottom Line• A healthy lifestyle is all about balance• All calories count• A balanced diet & habit of regular

physical activity are the keys• All foods and beverages can be part of a

healthy lifestyleACD2010

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