Intermittent Fasting for Obesity Treat .Intermittent Fasting for Obesity Treatment Victoria A. Catenacci,

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  • Intermittent Fasting for Obesity Treatment

    Victoria A. Catenacci, MDAssociate Professor, Division of Endocrinology, Metabolism, and Diabetes

    University of Colorado Anschutz Medical Campus

    DisclosuresNo conflicts of interest to disclose

    CASEMrs. D is a 42 yo female who presents to establish care, trying to lose weightPMH: gestational DMMeds: Mirena IUD, mviteWt 233 lbs, ht 54 (BMI = 40), BP 120/75, PE normalLabs: CBC, CMP, Lipids, TSH WNL, A1C 5.6%Enrolled in diabetes prevention program 6 months ago: Daily caloric restriction (1200-1500 kcal/day) Increased PA (300 min/week moderate intensity) Self-monitoring strategies (calorie counting, food and PA logs) Weekly group based-behavioral support

  • CASE After 3 months: wt 220 lbs (5% weight loss)After 6 months: wt 226 (3% weight loss) Doing well with exercise but reports increasing difficulty adhering to daily calorie goalOpen to weight loss medications in the future, but does not want to start yet She has read about fasting for weight loss and is wondering if you would recommend this strategy?

    Learning ObjectivesUpon completion of this program, the participant should be able to:

    Understand common fasting paradigms for weight lossDescribe the current evidence base for time restricted feeding (TRF) and intermittent fasting (IMF) as treatments for overweight/obesity.

    Humans evolved in environment where food was relatively scarce

    Mattson et al. Aging Research Reviews 39 (2017) 46-58

    Mammals have organs (liver, adipose tissue) that function as energy depots and enable fasting for various amounts of time depending on the species

    Metabolic, endocrine, and nervous systems evolved in ways that allow maintenance of high levels of physical and mental performance when in a food-deprived/fasted state

  • Hunting and Gathering in 2017.

    Smart phone app to record all ingestive events over 3 weeks.

    N = 156 (non-shift workers)

    Polar plot of aggregate data

    Most subjects ate frequently and erratically throughout wakeful hours.

    Only 5 hours (1AM to 6AM) where frequency of eating events declined.

    5 kcals5kcals

    Representative scatter plot of ingestive events (n=11)

    Lack of clustering in breakfast-lunch-dinner temporal pattern.

    Median daily eating duration was 14.75 hours

  • Eat LessEat Less Often!

    Fasting paradigms for weight loss are gaining popularity

    Male model Nicklas Kingoshares the regimen he used to take him from the grey suburbs of Copenhagen to the runways of Louis Vuitton in Paris

  • Cookbooks for Fasting???

    Fasting Paradigms for Weight Loss*no clear consensus on terminology

    Time Restricted Feeding (TRF): food intake is restricted to a window of

  • Why Consider Fasting Paradigms For Obesity Treatment?

    Daily caloric restriction (DCR) most commonly prescribed dietary strategy to induce weight loss1 Current guidelines recommend DCR (along with comprehensive

    lifestyle intervention) as cornerstone of obesity treatment2

    Typically results in 5-10% weight loss over 6 months3,4

    However, many find it difficult to adhere to conventional weight loss diets in which food is limited every day

    1. Julia et al. PLoS One. 2014;9(5). 2. Jensen et al. Circulation. 2014;129:S102-38. 3. Dansinger et al. JAMA. 2005;293(1):43-53. 4. Johnston et al. JAMA. 2014;312(9):923-33.

    Copyright restrictions may apply.

    Self-reported Dietary Adherence Declines Rapidly Within 4 Months: Scores of 4 Diet Groups,

    According to Study Month

    Dansinger, M. L. et al. JAMA 2005;293(1):43-53.

    Weight Loss in A Comprehensive Behavioral Weight Loss Interventiona Using DCRb

    LOCF analysis of N=170 participants in ongoing R01 DK 097266 (Catenacci) Optimal Timing of Exercise Initiation in a Group Based Behavioral Weight Loss Program

    a All participants received group-based behavioral support weekly for weeks 1-20, every other week for weeks 21-26 and monthly for weeks 27-52. Participants were randomized to received a 26-week supervised exercise intervention during weeks 1-26 (STANDARD) or 27-52 (SEQUENTIAL). b DCR, 1200-1600 kcals/day for women, 1500-1900 kcals/day for men.

    -40% -35% -30% -25% -20% -15% -10% -5% 0% 5%







  • Weight Regain After Weight Loss

    Adapted from Anderson et al. AJCN. 2001;74(5):579-84

    2001 Meta-Analysis of US Dietary Weight Loss Studies







    1 2 3 4 5

    % of Lost Weight


    Years after Weight Loss

    # of Studies with Data Available13 20 10 8 8

    77% of lost weight regained35% of lost

    weight regained

    Why Consider Fasting Paradigms For Obesity TreatmentCurrent dietary approaches only modestly effective

    Important to consider and rigorously evaluate alternative dietary strategies as part of a range of dietary approaches that can be offered to individuals desiring weight loss.

    Best approach for a given individual is likely to be the one they can adhere to over time

    Metabolic and Health Benefits of Fasting

    Mattson et al. Ageing Research Reviews 39 (2017) 46-58

  • Patients ask about this

    Fasting Paradigms for Weight Loss*no clear consensus on terminology

    Mattson et al. Ageing Research Reviews 39 (2017) 46-58

    Time Restricted Feeding (TRF): food intake is restricted to a window of

  • Garaulet et al. Int J Obes, 2013

    Importance of Meal Timing for Weight Loss N=420 adults enrolled in 20 week weight loss program (Mediterranean diet +

    cognitive behavioral techniques) Age 4211 yrs, BMI 31.4 5.4 kg/m2, 49.5% female Divided into Early (51%) and Late (49%) Eaters based on lunch time before and

    after 1500 hours No differences in EI, diet composition, estimated EE, appetite hormones, and

    sleep duration

    Gill et al. Cell Metab, 2015.

    Time-Restricted Feeding Elicits Weight Loss

    0 1224

    n=8 adults (BMI >25, eating window >14 hrs/day) Asked to restrict eating to 10 hrs/d, no other dietary changes Compliance assessed with smart phone app 3.4 kg weight loss at 16 weeks, maintained at 1 year

  • Pilot Study of TRF as a Weight Loss InterventionCOMIRB 18-0487, PI Elizabeth Thomas

    N=30 healthy adults with overweight/obesity randomized to TRF+RCD vs RCD alone TRF = energy intake restricted to 10 hour/day window RCD = standard reduced calorie diet (1200-1800 kcal/d)

    12 week intervention, 6 month follow upOutcomes: body weight, DXA, energy intake/eating patterns (smart phone app),glucose variability (CGM), PA and sedentary behavior,

    Fasting Paradigms for Weight Loss*no clear consensus on terminology

    Intermittent Fasting (IMF): recurring pattern of short fasting periods (little or no energy intake on fast days), with intervening periods of normal food intake.

    Alternate-day fasting (ADF)1-3 fast days/wk2 consecutive fast days/wk

    Total (100%) energy restriction on fast day Partial (>75%) energy restriction on fast day

    Mattson et al. Ageing Research Reviews 39 (2017) 46-58

    Why is IMF Appealing? Dieters do not have to count and restrict calories every day1

    Periodic nature of fasting may mitigate the constant hunger associated with DCR2

    Less complicated: this is the easiest diet I have ever been on, I just need to remember which days Ieat and which days I dont!

    1Johnstone A. Int J Obes (Lond). 2015;39(5):727-33.2Horne BD et al. Am J Clin Nutr. 2015; 102:464-70

  • But dont people just eat more on non-fast days?

    Short-term (8-12 week) weight loss studies using self-reported measures of EI suggest individuals do not fully compensate on fed days for the calorie deficits on fast days Partial ADF (10 weeks)EI on fed days 956% baseline requirements1 Partial ADF (12 weeks)EI on fed days 9910% baseline requirements2 Total ADF (8 weeks)EI on fed days 10313% baseline requirements3

    Some studies suggest carry-over effect of IMF reduction in energy intake of 23-32% on non-fasting days4,5

    1Klempel et al. Nutr J. 2010;9:352Varady et al. Nutr J. 2013 12:146 3Catenacci et al. Obesity 2016;24(9):1874-834Harvie et al. Int J Obes (2011): 35(5)714-72720115Harvie et al. Int J Obes (2013) British J Nutr

    What about Hunger? Total (100% energy restriction) ADF Hunger (daily VAS 10AM, 12PM, 2PM, 4PM) increased from baseline

    and did not decrease over 3 week study1

    Partial (75% energy restriction) ADF Hunger (daily 1-10 scale q 2h) increased at week 2 but no different

    from baseline at week 8 of the intervention2 Hunger (daily evening VAS scale) initially high but decreased by week 2

    and remained low over 8 week intervention3 Hunger (AUC fasting and postprandial VAS response to test meal)

    unchanged from baseline at week 84

    1Heilbronn et al. Am J Clin Nutr 2005; 81:69-73.2Johnson et al. Free radical biology & medicine. 2007;42(5):665-743Klempel et al. Nutr J. 2010;9:354Hoddy et al. Clin Nutr. 2016; 35(6)1380-85

    Is IMF Safe?

    Pilot Study Design26 adults (6 men, 20 women), BMI 30 kg/m2, age18-55

    Randomized 1:1 to alternate-day fasting (ADF) or daily caloric restriction (DCR)

    8 week intervention period (all food provided) ADF: Total (100%) energy restriction on fast days, ad libitum intake on fed daysa

    DCR: -400 kcal/dayb

    a On fed days, ADF provided diet estimated to meet energy requirements plus 5-7 optional food modules (200 kcals) b Considered standard of care dietary weight loss intervention when study was designed in 2006

    Catenacci et al, Obesity (2016) 24, 1874-1