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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, [email protected]
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
ACD2010
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
ACD2010
The Key Role of BalancePrevalence (%) of Overweight (BMI > 25)
Among Adults
MALE FEMALEMYANMAR 32 47
INDONESIA 10 27
who.int/infobase/2010
ACD2010
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
ACD2010
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
ACD2010
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
ACD2010
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).
ACD2010
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
ACD2010
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
ACD2010
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
ACD2010
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.
ACD2010
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
ACD2010
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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