Dietary therapy for obesity

 

The optimal management of overweight and obesity requires a mixture of diet, exercise, and behavioral modification. additionally, some patients eventually require pharmacologic therapy or bariatric surgery. the danger of overweight to the topic should be evaluated before beginning any treatment program. Selection of treatment can then be made employing a risk-benefit assessment. the selection of therapy depends on several factors including the degree of overweight or obesity and patient preference.
This topic will review the dietary therapy of obesity. Other aspects of treatment are discussed separately.


GOALS OF WEIGHT LOSS

— it’s important to line goals when discussing a dietary weight loss program with a personal patient. An initial weight loss goal of 5 to 7 percent of weight is realistic for many individuals.
• The first goal for any overweight individual is to forestall further weight gain and keep weight stable (within 5 pounds of its current level).
• The goal of the clinician is to spot and review with the patient a sensible weight loss goal. Most patients have a weight loss goal of 30 percent or more below current weight, which is unrealistic
• A successful program will result in a weight loss of quite 5 percent of initial weight A weight loss of quite 5 percent can reduce risk factors for upset, like dyslipidemia, hypertension, and DM In the Diabetes Prevention Program, a multi-center trial in patients with impaired glucose tolerance, weight loss of seven percent reduced the speed of progression from impaired glucose tolerance to diabetes by 58 percent .
• Loss of 5 percent of initial weight and maintenance of this loss may be a good medical result, whether or not the topic doesn’t reach his or her “dream” weight.
• Although a very difficult goal to realize, a body mass index (BMI) between 20 and 25 kg/m2 puts the topic within the lowest risk category

DIETARY ENERGY


Rate of weight loss

— the speed of weight loss is directly associated with the difference between the subject’s energy intake and energy requirements. Reducing caloric intake below expenditure ends up in a predictable initial rate of weight loss that’s associated with the energy deficit However, prediction of weight loss for a private subject is difficult thanks to marked intersubject variability in initial body composition, adherence, and energy expenditure Food records are often inaccurate. Most normal-weight people under-report what they eat by 10 to 30 percent, while overweight people under-report by 30 percent or more additionally, energy requirements are influenced by fidgeting, gender, age, and genetic factors ]. As examples:

• Men lose more weight than women of comparable height and weight after they adjust to eating any given diet because men have more lean body mass, less percent body fat, and so higher energy expenditure.
• Older subjects of either sex have a lower energy expenditure and thus slenderize more slowly than younger subjects; rate declines by approximately 2 percent per decade (about 100 kcal/decade)
• The importance of genetic factors is illustrated by a study of identical male twin pairs who were overfed to induce weight gain Twelve twin pairs were overfed by 1000 kcal/day for 84 of 100 days. The degree of weight gain at a continuing dietary caloric increment varied widely among the dual pairs (from 4.3 to 13.3 kg), in fact, there was 3 times the variance for both weight and fat mass among the dual pairs compared therewith within the dual pairs.
Approximately 22 kcal/kg is required to take care of a kilogram of weight in an exceedingly normal adult. Thus, the expected or calculated energy expenditure for a lady weighing 100 kg is approximately 2200 kcal/day. The variability of ±20 percent could give energy needs as high as 2620 kcal/day or as low as 1860 kcal/day. a median deficit of 500 kcal/day should end in an initial weight loss of roughly 0.5 kg/week (1 lb/week). However, after three to 6 months of weight loss, energy expenditure adaptations occur, which slow the bodyweight response to a given change in energy intake, thereby diminishing ongoing weight loss
There are several methods of formally estimating energy expenditure; we recommend using the WHO criteria This method allows a right away estimate of resting rate (RMR) and calculation of daily energy requirement. The low activity level (1.3 x RMR) includes subjects who lead a sedentary life. The high activity level (1.7 x RMR) applies to those in jobs requiring toil or patients with regular daily workout programs

Maintenance of weight loss

— it’s important for the overweight subject to know that achieving and maintaining weight loss is created difficult by the reduction in energy expenditure that’s induced by weight loss Weight loss maintenance is additionally difficult due to changes within the peripheral hormone signals that regulate appetite. Gastrointestinal peptides, like ghrelin, which stimulates appetite, and gastric inhibitory polypeptide, which can promote energy storage, increase after diet-induced weight loss. Other circulating mediators that inhibit intake (eg, leptin, peptide YY, cholecystokinin, pancreatic polypeptide) decrease. These hormonal adaptations favoring weight gain persist for a minimum of one year after diet-induced weight TYPES OF DIETS — the final consensus is that excess intake of calories from any source, related to a sedentary lifestyle, causes weight gain and obesity. The goal of dietary therapy, therefore, is to decrease energy intake from food. Conventional diets are defined as those below energy requirements but above 800 kcal/day These diets comprise four groups: • Balanced low-calorie diets/portion-controlled diets

• Low-fat diets

• Low-carbohydrate diets

• Mediterranean diet

• Fad diets (diets involving unusual combinations of foods or eating sequences)

Commercial weight loss programs and internet-based programs are discussed elsewhere .) Balanced low-calorie diets — Planning a diet requires the choice of a caloric intake so selection of foods to fulfill this intake. it’s desirable to eat foods with adequate nutrients additionally to protein, carbohydrate, and essential fatty acids. Thus, weight-reducing diets should eliminate alcohol, sugar-containing beverages, and most highly concentrated sweets because they rarely contain adequate amounts of other nutrients besides energy. Breakdown of some protein is to be expected during weight loss. When weight increases as a results of overeating, approximately 75 percent of the additional energy is stored as fat and therefore the remaining 25 percent as lean tissue. If the lean tissue contains 20 percent protein, then 5 percent of the additional weight gain would be protein. Thus, it should be anticipated that in weight loss, a minimum of 5 percent of weight loss are protein. A desirable feature of any calorie-restricted diet, however, is that it leads to very cheap possible loss of protein, recognizing that this can not be but 5 percent of the load that’s lost. Portion-controlled diets — One simple approach to providing a calorie-controlled diet is to use individually packaged foods, like formula diet drinks using powdered or liquid formula diets, nutrition bars, foodstuff, and pre-packaged meals which will be stored at temperature because the main source of nutrients. Frozen low-calorie meals containing 250 to 350 kcal/package are often a convenient and nutritious thanks to try this. we’ve often recommended the utilization of formula diets or breakfast bars for breakfast, formula diets or a frozen lunch entree for lunch, and a frozen calorie-controlled entree with additional vegetables for dinner. during this way, it’s possible to get a calorie-controlled 1000 to 1500 kcal per day diet. In one four-year study this approach resulted in early initial weight loss, which then was maintained I don’t recommend the utilization of formula diets alone because they are doing not provide adequate nutritional variety. Low-fat diets — Low-fat diets are another standard strategy to assist patients reduce, and the majority dietary guidelines recommend a discount within the daily intake of fat to 30 percent of energy intake or less in an exceedingly meta-analysis of trials comparing low-fat diets (typically 20 to 25 percent of energy from fats) with a bearing group consuming a usual diet or a medium fat diet (usually 35 to 40 percent of energy), there was greater weight loss (approximately 3 kg) with low-fat compared with moderate fat diets additionally, one report noted that individuals who successfully keep their weight reduced adopt three strategies, one in all which is eating a lower fat diet A low-fat dietary pattern with healthy carbohydrates isn’t related to weight gain. This was illustrated by the Women’s Health Initiative Dietary Modification Trial of 48,835 postmenopausal women over age 50 years who were randomly assigned to a dietary intervention that included group and individual sessions to push a decrease in fat intake and increases in fruit, vegetable, and grain consumption (healthy carbohydrates), but failed to include weight loss or caloric restriction goals, or a sway group which received only dietary educational materials After a mean of seven.5 years of follow-up, the subsequent results were seen:

• Women within the intervention group lost weight within the first year (mean of two.2 kg) and maintained lower weight than the control women at 7.5 years (difference of 1.9 kg at one year, and 0.4 kg at 7.5 years).

• No tendency toward weight gain was seen within the intervention group overall, or when stratified by age, ethnicity, or body mass index.

• Weight loss was associated with the amount of fat intake and was greatest in women who decreased their percentage of energy from fat the foremost. A similar, but lesser trend was seen with increased vegetable and fruit intake. A diet may be implemented in two ways. First, the dietitian can provide the topic with specific menu plans that emphasize the employment of reduced fat foods. in concert guideline, if a food “melts” in your mouth, it probably has fat in it. Second, subjects will be instructed in counting fat grams as another to counting calories. Fat has 9.4 kcal/g. it’s thus very easy to calculate the amount of grams of fat an issue can eat for any given level of energy intake. Many experts recommend keeping calories from fat to below 30 percent of total calories. In practical terms, this suggests eating about 33 g of fat for every 1000 calories within the diet. For simplicity, i take advantage of 30 g of fat or less for every 1000 kcal. For a 1500-calorie diet, this is able to mean about 45 g or less of fat, which might be counted using the nutrition information labels on food package

Low-carbohydrate diets

— Proponents of low-carbohydrate diets have argued that the increasing obesity epidemic is also partially thanks to low-fat, high-carbohydrate diets. But this could be dependent upon the kind of carbohydrates that are eaten, like energy dense snacks and sugar or high fructose containing beverages. The carbohydrate content of the diet is a very important determinant of short-term (less than two weeks) weight loss. Low (60 to 130 grams of carbohydrates) and really low-carbohydrate diets (0 to <60 grams) are popular for several years Restriction of carbohydrates ends up in glycogen mobilization and, if carbohydrate intake is a smaller amount than 50 g/day, ketosis will develop. Rapid weight loss occurs, primarily because of glycogen breakdown and fluid loss instead of fat loss. Low and really low-carbohydrate diets are simpler for short-term weight loss than low-fat diets, although probably not for long-term weight loss. A meta-analysis of 5 trials found that the difference in weight loss at six months, favoring the low carbohydrate over low fat diet, wasn’t sustained at 12 months Low-carbohydrate diets may have another beneficial effects with reference to risk of developing type 2 DM, coronary heart condition, and a few cancers, particularly if attention is paid to the kind additionally because the quantity of carbohydrate. A low-carbohydrate diet is implemented in two ways, either by reducing the whole amount of carbohydrate or by consuming foods with a lower glycemic index or glycemic load Glycemic index and cargo are reviewed separately. .) If a low-carbohydrate diet is chosen, healthy choices for fat (mono- and polyunsaturated fats) and protein (fish, nuts, legumes, and poultry) should be encouraged due to the association between saturated fat intake and risk of coronary heart condition. During 26 years of follow-up of ladies within the Nurses’ Health Study and 20 years of follow-up of men within the Health Professionals’ Follow-up Study, low carbohydrate diets within the highest versus lowest decile for vegetable proteins and fat were related to lower all-cause mortality (HR 0.80, 95% CI 0.75-0.85) and cardiovascular mortality (HR 0.77, 95% CI 0.68-0.87 ]. In contrast, low carbohydrate diets within the highest versus lowest decile for animal protein and fat were related to higher all-cause (HR 1.23, 95% CI 1.11-1.37) and cardiovascular (HR 1.14, 95% CI 1.01-1.29) mortality High protein diets — Some popular books recommend high protein diets In one trial, low-fat diets with 12 percent and 25 percent protein content were compared. Weight loss over six months was greater with the upper protein diet (9 versus 5 kg), but the difference was not significant at 12 and 24 months Higher protein diets may improve weight maintenance, as illustrated by the results of a study of 60 subjects randomly assigned to an occasional fat, high protein versus low-fat, high-carbohydrate diet after completing a four week very low calorie diet Among the topics who completed the three-month study (n = 48), the high protein diet group had significantly better weight maintenance (between group difference of two.3 kg). High dietary protein intake, thanks to its acid-producing load, increases urinary calcium excretion (with potential risk for bone loss and calcium stone formation) Urinary calcium excretion does appear to extend when dietary intake of protein increases ], and this might pose a long-term risk for nephrolithiasis. However, two small randomized trials that checked out bone metabolism found evidence that increased dietary protein may decrease bone resorption ]. one in all the trials found that increased intestinal absorption of calcium was primarily liable for the increased urinary excretion of calcium which the excreted calcium wasn’t coming from bone Mediterranean diet — The term Mediterranean diet refers to a dietary pattern that’s common in olive-growing areas of the Mediterranean area. Although there’s some variation in Mediterranean diets, there are some common components that include a high level of monounsaturated fat relative to saturated; moderate consumption of alcohol, mainly as wine; a high consumption of vegetables, fruits, legumes, and grains; a moderate consumption of milk and dairy products, mostly within the kind of cheese; and a comparatively low intake of meat and meat products. A meta-analysis of 12 studies involving eight cohorts found that a Mediterranean diet was related to improved health status and reductions in overall mortality, cardiovascular mortality, cancer mortality, and incidence of brain disease and Alzheimers Very low-calorie diets — Diets with energy levels between 200 and 800 kcal/day are called “very low-calorie diets,” while those below 200 kcal/day are often termed starvation diets. the idea for these diets was the notion that the lower the calorie intake the more rapid the load loss, because the energy withdrawn from body fat stores may be a function of the energy deficit. Starvation is that the ultimate very obesity diet and ends up in the foremost rapid weight loss. Although once popular, starvation diets are now rarely used for treatment of obesity. Very low-calorie diets haven’t been shown to be superior to standard diets for long-term weight loss. in a very meta-analysis of six trials comparing very low-calorie diets with conventional low-calorie diets, short-term weight loss was greater with very low-calorie diets (16.1 versus 9.7 versus percent of initial weight), but there was no difference in long-term weight loss (6.3 versus 5.0 percent like all diets, very low-calorie diets initially lead to substantial protein loss that diminishes with time. Other expected effects include reduction in pressure and improvement in hyperglycemia in diabetic patients.

• Subjects adhering to very low-calorie diets usually have a fall in force per unit area, especially during the primary week. Antihypertensive drugs, especially calcium channel blockers and diuretics, should usually be discontinued when a awfully low calorie diet is begun unless moderate to severe hypertension is present.

• Most diabetic patients eating very low-calorie diets have marked improvement in hyperglycemia. blood sugar concentrations fall within the primary one to 2 weeks, and remain lower as long because the diet is sustained. Those patients taking but 50 units of insulin or an oral hypoglycemic drug will usually be able to discontinue therapy ]. The side effects of very low-calorie diets include hair loss, thinning of the skin, and coldness. These diets are contraindicated for lactating and pregnant women, and in children who require protein for linear growth. like all diets, there’s increased cholesterol mobilization from peripheral fat stores, thus increasing the chance of gallstones. Very low-calorie diets should be reserved for subjects who require rapid weight loss for a particular purpose, like surgery. the load regain when the diet is stopped is usually rapid, and it’s better to require a more sustainable approach than to use a way that can’t be sustained.

 

 

Dietetic treatment of type 2 diabetes for overweight

obese people Clinical Guide for Clinical Nutrition of Type 2 Diabetes Overweight and Obese People

This guide aims to enhance clinical practice that leads to the best medical service in order to obtain optimum results against diabetes, which is a brief guide directed to guide overweight and obese adults with diabetes in particular. Within the field of work of specialized medical dietitians in diabetes, in addition to the specialization of psychological counseling, social counseling, therapeutic physical sports, educated physiotherapists, as well as general and specialized doctors and nurses. According to the leading diabetes specialist centers in the world, every diabetic patient needs evaluation – in addition to the clinical medical evaluation – in terms of his nutritional and metabolic needs, the nature of his metabolic deviation interfering with diabetes, the importance of identifying therapeutic goals related to obesity and nutrition, unhealthy lifestyle adjustments, and physical activity, and the gradual approach to achieve medical therapeutic dietary recommendations.

General Directory

There are strong evidences that weight loss improves the response to insulin and blood sugar control and levels of blood lipids and blood pressure in patients with type 2 diabetes, and also reduces the risk of developing an explicit type 2 diabetes condition in pre-diabetes and high-risk groups of type 2 infection. To choose the appropriate therapeutic medical approach for the patient, it is preferable to refer to the therapeutic nutritionist to assess the patient’s nutritional habits and physiological and medical needs, integrate the nutritional adjustments into the patient’s medical and therapeutic lifestyle and work towards achieving the desired treatment goals.

The therapeutic priorities of this target group of patients include the following elements:

1 – Weight loss

2 – Determination of meal contents of carbohydrates and distribution of daily carbohydrates on meals in fixed quantities in treatments with fixed doses of insulin.

3 – Taking into account the therapeutic dietary considerations related to the diseases that may accompany diabetes, such as high arterial tension, blood lipids and cholesterol.

The relative table of the main components of the daily food is listed later as a general guide in therapeutic feeding, and some adjustments are made according to the patient’s condition, metabolic, satisfaction, and physiological needs, and taking into account some conditions of his own taste in food. All of that is done by a specialized therapeutic nutritionist, according to an action plan that schedules the dates of reassessment and modification of the therapeutic food plan according to clinical and laboratory standards that include: blood pressure, A1c, recurrence of hypoglycaemia / high blood sugar accidents, hyperlipidemia, and daily blood sugar measurements. In addition to checking the sodium and potassium blood ions, and the vegetarian patients.

Weight loss

  • It is necessary to design and develop a systematic plan for lifestyle adjustments that includes changes in daily nutrition, physical activity, and unhealthy lifestyle behaviors with the goal of gradually and healthy weight loss (• the best rate of weight loss is gradually 5 – 1 kg per week or in two weeks) This is done by reducing the daily intake of calories by 250 – 500 calories (1C), and the total daily calories should not be less than 1000-1200 calories for women, and 1200-1600 for men, and determination of the appropriate daily calories depends on the nutritionist’s evaluation of the patient’s daily intakes. (1) • Reducing 5-10% of the patient’s weight provides us with a significant improvement in controlling blood sugar in diabetics, and helps prevent the development of individuals with early diabetes in the pre-diabetes condition. The amount of weight loss depends on the condition of each patient and their data, and progressively proceeds until the appropriate BMI is achieved and / or shared with the amount of achievement of other treatment goals. (It is necessary to direct patients of this target group to the therapeutic and educated dietitians to teach them how to adjust the food rations and help them in practice, which is an effective way of managing weight) Patients should be provided with experiences in alternatives to preserved food designed for weight loss called (replacement meal) under the supervision of a nutritional specialist if they want to use them as alternatives to regular meals.

(With attention to the fact that they contain big amounts of potassium, and the need to reset medications that reduce blood sugar • in spite of the fact that stomach bariatric surgery may result in the nutritional and medical risk to the patient, it is still an effective option when used according to its needs) such as a mass index Body BMI> kg / m², or BMI> kg / m² with other participatory diseases in the patient ()

Till now, there is a limited evidence supporting recommendations for gastric bypass for BMI> kg / m² even if they have type 2 diabetes.

 

Large food ingredients

Fats

Percentage

There is general agreement on the importance of the quality of fat as well as its amount, and it is recommended that the total fat intake per day be less than 35% of the total daily calories. (2B) • The amount of saturated fat is set> 7% of the total daily calories. (1B) • The amount of mono-bonded and polyunsaturated fats remaining is equivalent to the total recommended fat calories. (2B) • The amount of cholesterol in the food is determined> 300 mg / day for people with LDL cholesterol> mg / dl. 1C

Recommended

Eat mono- and polyunsaturated fat (such as olive oil, nuts / seeds, avocado). (1B) • Eat fish types rich in fatty acids (omega-3) (120 g salmon, trout, sardines, tuna) twice per week as a good source of omega-3 fatty acids. 1B

 

Not recommended

For foods rich in saturated fats such as beef, ribs, whole milk products, and rich milk products (creamy and liquid cooked cheese, full-fat milk and milk) • Foods containing trans fats (fast food, pastries and baked goods prepared for commercial circulation, and some Types of margarine like ghee. Foods rich in cholesterol such as (egg yolks, and organs of the guts of animals such as the liver, marrow, and drops)

 

Protein

Daily fines

The daily protein intake should not be less than 2.1 g / kg of adjusted body weight (ABW) Weight Body Adjusted = ideal weight + IBW (weight body Ideal 25.0). Current weight – ideal weight. This amount is generally equivalent to 20- 30% of the total daily calories. (1B) There are no reliable scientific data that support increasing the daily intake of protein to 2 g / kg of adjusted body weight ABW • Available data confirm that eating protein portions in the meal helps to feel fullness. Reducing the content of meals, which increases the feeling of hunger), as a moderate increase in the protein content of the meal decreases the appetite for food, and this helps to continue Use weight (2B) and protein intake also helps reduce muscle mass loss in the body. (2B)

Recommended

Eat fish meat, skinless chicken meat, skimmed or low-fat dairy products, nuts, seeds, and legumes.

 

Not recommended

  • Sources of protein rich in saturated fats (cow and lamb, ribs, pork, full-fat dairy products) in relation to these nutritional sources with a high risk of cardiovascular disease.

Diabetics with kidney disease

Although decreasing the total calories consumed per day will also decrease the amount of proteins consumed, the kidney patients must seek advice from the kidney specialist before increasing the total or the ratio percentage of protein in their diet.) • Rationing in protein is no longer recommended

 

The daily diet of diabetic nephropathy patients and restricting them to less than 8,0 g / kg of weight, as it was found that this does not change blood sugar control or coronary heart risk criteria, and it has no role affecting the renal impairment of the renal renal function in patients. A

Carbohydrates

Percentage

 

The percentage of carbohydrates in the total daily caloric intake is 40-45 (1% .C) • The minimum carbohydrate for daily feeding must be 130 grams (1C) Patient

Considerations for glucose indicator / carbohydrate loading and glucose loading

The rules for index glycemic and load glycemic are important factors that the patient must know and care for to follow in daily food when choosing carbohydrate foodstuffs • It is recommended to choose foods with low glucose indicator. 2B) For example: whole grains, legumes, fruits, veggies, most vegetables

Recommended

Eating vegetables, fruits, legumes, whole grains, and processed grains is recommended to be kept to a minimum (not removed from the rest of its dietary fibers).

Not recommended

Table sugar, crushed purified starch, industrially processed fiber-free grains, starchy foods, sugary drinks, pasta of various kinds, white bread, white rice (2B) • Low-fiber cereals (peeled) and white potatoes can be eaten in limited quantities (2B)

 

Dietary Fibers

It is recommended to eat 14 grams of fiber / 1000 calories (equivalent to 35-35 grams / day), (1B) • If a well tolerated patient can eat 50 grams of dietary fibers to improve high blood sugar levels after a meal. (2A) • Fibers in uncooked foods such as vegetables, fruits, seeds, nuts, and legumes are good to eat but need to take fibrous supplements with them such as psylium, resistant starch, and glucan beta.

Fine nutritional ingredients

Sodium

It is recommended that the daily intake of sodium> 2300 mg) equal to one teaspoon of salt (/ day. 1A) • It is recommended to reduce the amount to 1500 mg / day for people over the age of 50 years, including patients with chronic kidney disease. (2B) • It is advised to recommend the patient to gradually reduce salt intake.

Potassium

  • It is recommended that the daily intake of potassium is 4700 mg unless the patient has a problem with the excretion of potassium • Potassium helps to neutralize the intake of sodium by increasing the activation of sodium excretion mechanisms through the kidney • Foods rich in potassium include bananas, mushrooms, spinach and almonds in addition to Pan fruits and vegetables

Nutritional supplements

For some patients without nutritional deficiency and malnutrition, data on this topic do not support the use of vitamins and mineral electrolytes to improve blood glucose control or the use of herbal supplements or spices to enhance blood sugar control

 

Non – nutritive sweeteners

The U.S. Food and Drug Administration has stated that it is safe to use all artificial non-nutrient sweeteners in moderate quantities daily (e.g. one diet soda can per day), while artificial non-household sweeteners can be used in a larger amount daily

Life behavioral modifications and physical physical activity

Physical activity must be included within the medical nutritional prescription, as increased physical musculoskeletal activity is a component integrated in any weight-loss program, as well as it raises the benefits of controlling blood sugar to the upper limits, and contributes to the prevention of cardiovascular disease or cerebral. (1B) • Mild physical exercise is required at least 60-90 minutes five times a week at least, as this leads to weight loss, unless the patient has an indication for this effort in timing or intensity. (1B) • Physical activity should be a combination of strength, flexibility, and cardiovascular revitalization exercises, to achieve or increase the muscle mass in the body.