Affiliate Conference Call

September 26, 2007

Weight Management Programs

Introduction

  • New Joslin publication coming out in Early November
  • Calorie King relationship - and that JDC will be on the COVER of the 2008 books!
  • Joslin Nutrition Clinical Guidelines – brief review
  • Recent publications
  • Diabetes Spectrum – Summer 2007; The Art and Science of Obesity Management
  • Gardner, et al. JAMA 2007;297:969-977 (see abstract below)

Affiliate Weight Management Programs

  • HMR sites (2-3 of our Affiliates use this)
  • Bariatric surgery programs - and how they interact with Joslin Affiliates
  • Collaboration with other existing hospital based weight control programs)
  • Custom designed programs for your diabetes patients

Joslin Boston's WHY WAIT program

  • Key components of the program (staff, diet, exercise, length of time, etc)
  • Key findings - outcomes

Weight Management Issues going forward

  • Role of diabetes medication and weight loss
  • Weight control medications
  • General Q and A
  • Do you think people with diabetes prefer being in their own Weight Management program - or do they not mind being blended in with others?
  • Do you think there are ways to foster better links with existing wt management programs in your communities for marketing purposes?- ex: do Wt Watchers, Jenny Craig, etc know about your diabetes services?

Two recent article abstracts:

Comparison of the Atkins, Zone, Ornish, and LEARN Diets for Change in Weight and Related Risk Factors Among Overweight Premenopausal Women: The A TO Z Weight Loss Study: A Randomized Trial

Christopher D. Gardner, PhD; Alexandre Kiazand, MD; Sofiya Alhassan, PhD; Soowon Kim, PhD; Randall S. Stafford, MD, PhD; Raymond R. Balise, PhD; Helena C. Kraemer, PhD; Abby C. King, PhD JAMA.2007;297:969-977.

Context Popular diets, particularly those low in carbohydrates,have challenged current recommendations advising a low-fat,high-carbohydrate diet for weight loss. Potential benefits andrisks have not been tested adequately.

Objective To compare 4 weight-loss diets representinga spectrum of low to high carbohydrate intake for effects onweight loss and related metabolic variables.

Design, Setting, and Participants Twelve-month randomizedtrial conducted in the United States from February 2003 to October2005 among 311 free-living, overweight/obese (body mass index,27-40) nondiabetic, premenopausal women.

Intervention Participants were randomly assigned to followthe Atkins (n=77), Zone (n=79), LEARN(n=79), or Ornish (n=76) diets and receivedweekly instruction for 2 months, then an additional 10-monthfollow-up.

Main Outcome Measures Weight loss at 12 months was theprimary outcome. Secondary outcomes included lipid profile (low-densitylipoprotein, high-density lipoprotein, and non–high-densitylipoprotein cholesterol, and triglyceride levels), percentageof body fat, waist-hip ratio, fasting insulin and glucose levels,and blood pressure. Outcomes were assessed at months 0, 2, 6,and 12. The Tukey studentized range test was used to adjustfor multiple testing.

Results Weight loss was greater for women in the Atkinsdiet group compared with the other diet groups at 12 months,and mean 12-month weight loss was significantly different betweenthe Atkins and Zone diets (P<.05). Mean 12-month weight losswas as follows: Atkins, –4.7 kg (95% confidence interval[CI], –6.3 to –3.1 kg), Zone, –1.6 kg (95%CI, –2.8 to –0.4 kg), LEARN, –2.6 kg (–3.8to –1.3 kg), and Ornish, –2.2 kg (–3.6 to–0.8 kg). Weight loss was not statistically differentamong the Zone, LEARN, and Ornish groups. At 12 months, secondaryoutcomes for the Atkins group were comparable with or more favorablethan the other diet groups.

Conclusions In this study, premenopausal overweight andobese women assigned to follow the Atkins diet, which had thelowest carbohydrate intake, lost more weight and experiencedmore favorable overall metabolic effects at 12 months than womenassigned to follow the Zone, Ornish, or LEARN diets. While questionsremain about long-term effects and mechanisms, a low-carbohydrate,high-protein, high-fat diet may be considered a feasible alternativerecommendation for weight loss.

Effects of bariatric surgery on mortality in Swedish obese subjects.

Sjöström L, Narbro K, Sjöström CD, Karason K, Larsson B, Wedel H, Lystig T, Sullivan M, Bouchard C, Carlsson B, Bengtsson C, Dahlgren S, Gummesson A, Jacobson P, Karlsson J, Lindroos AK, Lönroth H, Näslund I, Olbers T, Stenlöf K, Torgerson J, Agren G, Carlsson LM; Swedish Obese Subjects Study. N Engl J Med. 2007 Aug 23;357(8):741-52

Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.

BACKGROUND: Obesity is associated with increased mortality. Weight loss improves cardiovascular risk factors, but no prospective interventional studies have reported whether weight loss decreases overall mortality. In fact, many observational studies suggest that weight reduction is associated with increased mortality. METHODS: The prospective, controlled Swedish Obese Subjects study involved 4047 obese subjects. Of these subjects, 2010 underwent bariatric surgery (surgery group) and 2037 received conventional treatment (matched control group). We report on overall mortality during an average of 10.9 years of follow-up. At the time of the analysis (November 1, 2005), vital status was known for all but three subjects (follow-up rate, 99.9%). RESULTS: The average weight change in control subjects was less than +/-2% during the period of up to 15 years during which weights were recorded. Maximum weight losses in the surgical subgroups were observed after 1 to 2 years: gastric bypass, 32%; vertical-banded gastroplasty, 25%; and banding, 20%. After 10 years, the weight losses from baseline were stabilized at 25%, 16%, and 14%, respectively. There were 129 deaths in the control group and 101 deaths in the surgery group. The unadjusted overall hazard ratio was 0.76 in the surgery group (P=0.04), as compared with the control group, and the hazard ratio adjusted for sex, age, and risk factors was 0.71 (P=0.01). The most common causes of death were myocardial infarction (control group, 25 subjects; surgery group, 13 subjects) and cancer (control group, 47; surgery group, 29). CONCLUSIONS: Bariatric surgery for severe obesity is associated with long-term weight loss and decreased overall mortality. Copyright 2007 Massachusetts Medical Society.

Medical Nutrition Therapy

Comparison of Nutrition Guidelines from Joslin and ADA

Note: Items in grey shade are adapted from the text of the ADA paper to match items in Joslin Guidelines, but are not part of the formal list of recommendations that are in black and have an evidence rating matching it.

  • American Diabetes Association
/
  • Joslin Guidelines for Overweight and Obese…..

Calories /
  • In overweight and obese individuals, modest weight loss improves insulin resistance.(A)
  • Structured programs that emphasize lifestyle changes, including education, reduced energy and fat (30% to total energy), regular physical activity, and regular participant contact can produce long term weight loss on the order of 5-7% starting weight. Lifestyle change should be the starting approach to wt loss. (A)
  • Low carb diets (<130g/day) are not recommended for treatment of overweight /obesity. (B)
  • Weight loss meds and bariatric surgery are options for some pts (B)
  • Standard diets provide 500-1000 fewer calories than estimated for maintenance to have 1-2 lb loss/wk
  • Meal replacements (liquid or solid prepackaged) used once or twice daily can result in significant weight loss, however they must be continued indefinitely if wt loss is to be maintained.
/
  • Aim for modest weight loss of one pound every 1-2 weeks
  • Reduction of daily calorie intake by 250 to 500 calories
  • Weight loss diet should supply no less than 1000-1200 kcal/day for women and 1200-1600 kcal/day for men
  • Continue with weight reduction until BMI reaches normal range (18.5-25 kg/m2) or agreed upon BMI goal is reaches
  • Meal replacements, medications and bariatric surgery are options for some patients

Protein /
  • For individuals with diabetes and normal renal function, there is insufficient evidence that usual protein intake (15-20% of energy) should be modified. (E)
  • In individuals with type 2 diabetes, ingested protein does not increase plasma glucose concentration but does increase serum insulin response, and thus protein should not be used to treat acute or prevent nighttime hypoglycemia.. (A)
  • High protein diets are not recommended as a method for weight loss at this time. Long term effects of protein intake >20% of calories on DM and complications are unknown. Although short term weight loss and improved glycemia may be shown, long term benefits have not been established. (E)
/
  • Aim for approximately 20-30% of total calories
  • Evidence supports higher protein intake to help maintain lean body mass during weight reduction and aid in satiety
  • Individuals with signs of kidney disease (albuminuria, proteinuria or creatinine clearance <60 ml.min) should consult with nephrologist before increasing protein to this level. Protein intake should be modified but not lowered to an amount that may jeopardize health or increase risk for malnutrition

Fat and Cholesterol /
  • Saturated fat <7% (A)
  • Minimize intake of trans fats (E)
  • Lower dietary cholesterol to <200 mg/day (E)
  • Two or more servings of fish per week (with the exception of commercially fried fish filets) provide recommended sources of omega-3 fatty acids (B)
/
  • Saturated fat <7% in individuals with LDL-C >100 mg/dl
  • PUFA up to 10% total calories; MUFA 15-20% total calories
  • Avoid foods high in trans fat
  • Lower cholesterol to < 200 mg if LDL-C > 100 mg/dl
  • Aim for oily fish two times per week

Carbohydrate /
  • A dietary pattern that encourages carb from fruits, vegetables, whole grains, legumes and lowfat milk is encouraged (B)
  • Restricting total carbohydrate to <130 g/day is not recommended for management of diabetes. (E)
/
  • Approximately 40% of total calories from carbohydrate but no less than 130 g carb per day
  • Emphasize fresh fruits and vegetables, legumes and minimally processed grains

Sweeteners /
  • Non-nutritive sweeteners and sugar alcohols are safe when consumed within Acceptable Daily Intake levels established by FDA; (A)
/
  • Not addressed

Fiber /
  • Consume a variety of fiber containing foods. Evidence is lacking to recommend a higher fiber intake for people with diabetes than for the population as a whole. (B) Acknowledges that while a high fiber diet 50 g/day is associated with improved metabolic outcomes, for most adults aiming for increasing to USDA recommended levels of 14 g fiber per 1000 kcals should be the first goal
/
  • Aim for minimum of 20-35 g fiber/day; 50 g/day if tolerated. Fiber from unprocessed food preferred, but fiber goal can be reached via supplements such as psyllium and beta-glucan

Glycemic Index /
  • The use of glycemic index and load may provide a modest additional benefit over that observed when total carbohydrate is considered alone. (B)
/
  • Choose foods with low glycemic index and low glycemic load

Sodium /
  • For patients with diabetes and symptomatic heart failure, dietary sodium intake of <2,000 mg/day may reduce symptoms (C)
  • In normotensive patients and hypertensive persons, a reduced sodium intake (e.g., 2,300 mg/day) with a diet high in fruit, vegetables and low-fat dairy products lowers blood pressure. (A)
/
  • Not addressed

Alcohol /
  • If adults with diabetes choose to drink alcohol, daily intake should be limited to a moderate amount (one drink or less/day for women; two drinks or less per day for men)(E)
/
  • Not addressed

Vitamins and Minerals /
  • There is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes who do not have underlying deficiencies. Exceptions include folate for prevention of birth defects. (A).
  • Routine supplementation with antioxidants, such as vitamins E and C and carotene is not advised because of lack of evidence of efficacy and concern related to long term safety. (A)
  • No clear benefit from chromium and thus can not be recommended. (E)
/
  • Not addressed

Other /
  • Monitoring carbohydrate, where by carb counting, exchanges or experienced based estimation, remains a key strategy in achieving glycemic control.
  • Plasma glucose monitoring can be used to determine whether adjustments in foods and meals will be beneficial or if medications need to be combined with MNT. (EC)
/
  • Meal-to-meal carbohydrate consistency is important for patients on fixed medication/insulin programs
  • Aim for 150-175 minutes per week of moderate intensity physical activity; with target of 60-90 minutes most days of the week

Adapted from: Bantle, J, Wylie-Rosett, J, Albright, et al. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. 2006. Diabetes Care. 29(9): 2140-2157. and Joslin Nutrition Guidelines for Overweight and Obese Individuals with Type 2 Diabetes: