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Your Clients Are What They Eat: Balancing Weight with Diet Part I

Miller, Gary D. Ph.D.

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Learning Objective To learn the components of a healthy diet and what it takes to lose weight. A number of different dietary strategies consistent with overall health and weight management are included. Key components of successful weight loss and weight management are listed, and a review of several weight loss plans is provided.

This article summarizes the key aspects of a healthy diet, especially as it relates to weight loss. Learn the components of a healthy diet and what it takes to help your clients lose weight, as well as a number of different dietary strategies consistent with overall health and weight management.

Gary D. Miller, Ph.D., is an associate professor of nutrition at Wake Forest University. His research focuses upon the effect of obesity and weight loss on comorbidities and physical function in older adults.

A healthy diet is essential for weight management, for prevention of chronic diseases such as diabetes, cancer, and cardiovascular disease, and for maintenance of overall good health. A proper diet is especially needed for a person who engages in exercise or leads a physically active lifestyle, because it provides the necessary energy and nutrients. Nutrients found in foods provide structure to tissues, regulate body processes, and supply the body with the energy it requires. This article will focus upon diet as it relates to weight management, including weight loss, weight maintenance, and prevention of weight gain.

To lose weight, the number of calories eaten must be fewer than the calories expended; this provides a negative calorie balance. Losing 1 lb of fat requires a calorie deficit of 3,500 calories. To lose this much in 1 week, there must be a negative balance of 500 fewer calories each day; this is accomplished by eating less, being more active, or a combination of the two. For weight loss, your client may be able to eat ice cream and candy bars and still lose weight, as long as calorie intake is less than calorie expenditure. The bottom line is that calories count, independent of the composition of the diet. For the long term, however, obtaining calories from fruits, vegetables, whole grains, and good sources of protein as part of a low-fat diet will not only facilitate weight management, it will ensure better health.

There has been much hype and controversy regarding the best diet for losing weight. A further challenge is the prevention of weight regain, a common experience for those who lose weight. In addition, preventing weight gain in the first place has become a major approach to deal with the obesity issue. Choosing a diet that results in a permanent lifestyle change is essential for success. Basic principles underlying healthy dietary strategies that will allow your client to take steps towards successful weight management will be discussed in this article.

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Healthy Diet Plans for Weight Management

The general principles for maintaining a healthy diet that promotes weight management include managing calorie intake and ensuring that the diet provides proper levels of essential nutrients and other substances found in foods that promote health. By selecting a variety of foods, especially those that are nutrient dense, yet low in calories, your client will more likely meet the recommendations for vitamins, minerals, and other nutrients. Individuals who have been successful in weight management share a number of similar characteristics regarding the foods in their diet and behaviors related to their eating. By following these tips, your client is more likely to succeed in losing weight and keeping it off.

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  • Eat lots of fruits and vegetables. These low-calorie, high-nutrient foods have plenty of fiber (see the next item), vitamins, minerals, and non-nutrients that contribute to our overall health.
  • Fill up on fiber. Some of the signals from our body telling us to stop eating at a meal are related to the volume of food in the stomach, not to the number of calories. Fiber provides few, if any calories, yet adds bulk to the food. Eating a large volume of low-calorie foods that are high in fiber will expand the stomach and send satiety signals to the brain. Have your client eat large amounts of high-fiber foods with low caloric densities, including fruits, vegetables, whole grains, and legumes.
  • Choose a low-fat diet. Although there is continued debate over whether a low-fat diet (less than 25% of total calories) contributes to successful weight management, research has found that simply lowering dietary fat intake helps prevent obesity and promote weight loss because of the high caloric density and small volume of high-fat diets (1, 2). Individuals are more likely to overeat when presented with high-fat foods, and hence consume more calories (3).
  • Be wise when selecting sources of protein. Obtain protein from foods that are low or moderate in total fat and low in saturated fatty acids, such as nonfat dairy, egg whites, fish, lean meats, legumes, and seeds. Not only will this reduce total calories by lowering fat intake; proteins also have been shown to provide greater satiety and alertness than carbohydrates (4).
  • Drink fluids. Many people do not drink enough fluids to maintain hydration. The body's need for fluid is frequently misinterpreted, and instead of drinking, people will eat food that the body really does not need. Drinking plenty of water and calorie-free beverages (such as tea, coffee, and diet soft drinks) throughout the day makes one less likely to drink or eat foods that contain calories.
  • Monitor portion sizes-more is NOT better. The amount of food that is considered a "normal" portion has escalated over the past 25 years. Researchers have found that the portion size of foods in eating establishments are now 2 to 8 times greater than recommended serving sizes (5). This also has influenced serving sizes at home, as larger portions of foods are served there, too. More calories are consumed when more food is present on a plate. Think smaller portions not only when eating out, but also in food prepared at home.
  • Do not skip breakfast. Successful dieters report eating breakfast every day (6). Eating a morning meal helps reduce later consumption of fats, and minimizes impulsive snacking over the course of a day (7). Without breakfast, it is common to compensate and eat more calories throughout the rest of the day than when breakfast is consumed.
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  • Never say "no" to a food. Nearly all foods can be fair game. Even when trying to restrict calories, indulging in a favorite treat is okay as long as portion sizes are controlled, and the foods do not become a regular luxury. Likewise, don't develop a phobia for a food, food group, or component of food. Avoiding carbohydrates, fruits, sugars, protein, or fat-the basis for many fad diets-should not be practiced; instead, moderation is the key.
  • Write it down. Time and time again, research shows that monitoring the amount and type of food eaten plays an important role in successful weight loss and maintenance. This requires writing down all the drinks and foods consumed in a day, and determining the total caloric intake. Although this can sometimes be tedious, it works! Your clients will become acutely aware of all the food they consume, and this awareness will initiate behavior changes to control the size, frequency, and types of food eaten.
  • Gradual on, slow coming off. Although it may not seem like it, most people gain weight slowly, with only a few pounds added every year. Over a decade this amounts to a 20- to 30-lb increase in body weight. Because weight is put on slowly, there should be the same expectations for weight loss. Have your clients make lifestyle dietary alterations that can be maintained for the long term, instead of changes that last just for a short period. Help them make plans for a gradual weight loss, with a maximum of 2 lbs lost per week. A realistic target is to lose approximately 5% to 10% of initial body weight after 6 months. Your client will not only look and feel much better, but will be healthier as well. This level of weight loss results in significant improvements in blood pressure, insulin resistance, and blood cholesterol levels, and this goal can be achieved with moderate calorie restriction. Although your client may find it possible to lose substantially more weight than this each week, exceeding these limits causes mostly loss of water and lean body mass. By preserving lean body mass, the body's metabolic rate can be maintained. To consume most nutrients and help preserve lean body mass, a minimum calorie intake of 1,100 to 1,200 calories per day for women and 1,400 to 1,500 calories per day for men is recommended. Provide your clients with a calorie deficit goal of 500 to 1,000 fewer calories per day than their current diet, permitting a 1- to 2-lb weight loss per week. This can be accomplished by lowering dietary intake by 250 to 500 calories a day, and increasing energy expenditure by 250 to 500 calories a day through physical activity. This modest calorie restriction can help ensure that the diet is incorporated into a lifestyle change.
  • Exercise, exercise, exercise. As mentioned, those who are successful at losing a significant amount of weight and keeping it off exercise regularly, up to more than an hour per day, most days of the week. This helps create a calorie deficit beyond what diet alone would provide. However, to have the energy to participate in an exercise regimen, it is important to have a healthy and nutritious diet. This includes balancing nutrients with carbohydrates, protein, fat, vitamins, and minerals. When restricting calorie intake, it is common to become fatigued when exercising, as fuel stores of glycogen in muscles and liver are lower. Your clients may complain that they do not have the energy to exercise. Instructing them to eat carbohydrates in a snack of fruit or crackers, or a meal approximately 30 to 60 minutes before their exercise session, can help lessen this fatigue. The food will supply the fuel that the body needs for exercise.
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Specific Diet Plans

Consulting a registered dietitian is a viable option for an individual trying to lose weight. Dietitians can provide expert nutrition advice that is tailored to the individual, and can be found through a referral network by typing in a targeted zip code on the American Dietetic Association Web site (www.eatright.org). Available nutrition professionals are listed along with their area of expertise. These experts will teach people what and how to eat, not just how to "diet." They can help individuals lose weight, keep it off, and manage the U.S. food supply in a personalized program.

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Several dietary options are available that follow the basic principles for successful and healthy weight loss and maintenance. They can be used in conjunction with a registered dietitian. One example is from Walter Willett, M.D., M.P.H., at the Harvard School of Public Health. He has developed the Be Healthy Pyramid for overall health, including the promotion of weight loss and maintenance (Figure 1) (8). Key points of this pyramid are found in his Eat, Drink, and Be Healthy book and are discussed as follows:

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  • Watch your weight. This forms the foundation for Dr. Willett's pyramid (along with the incorporation of daily exercise). The importance of this recommendation is based upon statistics showing that being overweight or obese afflicts nearly two thirds of the U.S. population, and that the combination of poor diet and physical inactivity is the second leading cause of preventable death in the U.S., causing 400,000 deaths annually (9, 10).
  • Eat fewer bad fats and more good fats. Plant and fish oils containing unsaturated fatty acids can be readily consumed within calorie limits, but foods that are high in saturated fatty acids, such as most animal products, trans-fats, hydrogenated fatty acids, and tropical oils like coconut and palm oils should be avoided or limited.
  • Eat whole-grain carbohydrates. Carbohydrates from whole grains should be consumed at most meals.
  • Choose healthier sources of proteins. Dr. Willett's pyramid encourages intake of nuts and legumes 1 to 3 times per day; fish, poultry, and eggs 0 to 2 times daily; and red meat to be eaten sparingly.
  • Eat plenty of vegetables and fruits. These nutrient-rich foods provide lots of fiber and essential vitamins and minerals. Consuming at least 5 servings per day of these foods is suggested.
  • Use alcohol in moderation. In moderation (1 to 2 drinks per day), alcohol can reduce heart attacks, whereas alcohol abuse can have detrimental effects upon nearly every organ system in the body.
  • Take a multivitamin for insurance. Many diseases are associated with low intakes of key vitamins, especially folic acid, vitamin B12, vitamin B6, and vitamin D. Dr. Willett suggests that taking a supplement containing vitamins not exceeding the recommended levels may help prevent chronic diseases.

Dr. Willett's diet plan is just one option available for your clients. If they choose to follow this plan along with monitoring portion sizes, their diets will be consistent in providing good health and promoting weight loss and weight maintenance.

A number of commercial enterprises have developed their own diet plans and have marketed them as alternatives for losing weight. Their personnel are knowledgeable in nutrition, and they provide group support for their clients. One such company is Weight Watchers®. Its program is typically commended by nutritionists and health professionals because the program encourages eating foods consistent with an overall healthy diet, stresses behavioral changes, promotes regular exercise, and aids in relapse. Its success stems from its user-friendly approach. Foods are assigned a certain number of points based upon their calorie content, and clients eat a defined number of points per day. Clients choose their foods based upon their likes and dislikes. This provides flexibility and independence in menu planning, yet it provides structure to the regimen. Group sessions help build a social network to assist in problem solving and strategies to prevent relapse. Individuals pay a certain amount for each pound they lose. This program has had relative long-term success in helping enrollees lose weight and then keep it off. More than 70% of participants in Weight Watchers® were able to stay below their initial weight after 5 years, and 42% lost and maintained at least a 5% weight loss (11). Weight Watchers® can be an excellent resource because it provides nutrition expertise, whereas the fitness professional provides the necessary exercise expertise for the client.

Another successful weight loss diet strategy involves incorporating meal replacements, such as prepared shakes and snack bars into a daily diet. In these plans, clients follow a low-calorie diet, whereby 1 or 2 meals per day are replaced by commercially available, reduced-calorie products that are vitamin and mineral fortified. For example, SlimFast® provides meal replacements as shakes, soups, and pastas. Studies show that those using meal replacements lose significantly more weight and keep it off for at least a 1-year period than individuals adhering to a conventional reduced-calorie diet (12). Participants using meal replacements lost, on average, approximately 5 more pounds than those on conventional reduced-calorie diets. There was better compliance for patients on meal replacements than with the conventional reduced-calorie diet. Their effectiveness is generally attributed to the structure they provide with menu planning; they replace potentially calorie-dense foods with foods of known nutrient and calorie contents, and they lower the stress associated with food selection. Meal replacements may help one adopt a healthy lifestyle, and they provide guidance about reasonable portion sizes. The fitness professional can help guide clients into the proper use of these products by recommending the number of meals to replace and incorporating fruits and vegetables as snacks. (For more information on prepared meals and menu planning, see the Eye on the Future column in this issue.)

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Summary

These programs serve as examples that can be recommended for your client. Other available options provide nutrition advice consistent with healthy eating for weight management. One of these, the Mayo Clinic Healthy Weight Pyramid (http://www.mayoclinic.com/invoke.cfm?objectid=357FAABB-312F-414A-A8D6401C15EE66B4), provides the foundation of a healthy diet with an emphasis upon weight management (Figure 2). Another healthy choice, sponsored by Shape Up America, is known as Shape Up and Drop 10TM (http://www.shapeup.org/sud10.html). These programs, along with those discussed previously in this article, share common principles. First, the foods consumed are consistent with promoting good health, are safe, and meet requirements for nutrients. Second, the menus provide flexibility to account for individual tastes. Third, the timing and content of meals are designed to minimize hunger and fatigue. This would include moderate restriction, gradual weight loss, and incorporation of meals and snacks throughout the day. Fourth, the foods are readily obtainable and socially acceptable. The diets recommend making reasonable changes to typical dietary habits, and the changes can then become part of a permanent lifestyle that can promote long-term weight maintenance.

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Successful, healthy weight loss includes a moderate calorie-restricted diet that emphasizes whole grains, abundant fruits and vegetables, low intake of saturated fatty acids, and incorporation of a regular exercise program. Weight loss goals should be set to lose no more than 2 lbs per week, keeping in mind that a calorie deficit of 3,500 calories is equal to a loss of 1 lb of fat. Health improvements are observed with as little as a 5% to 10% weight loss. Greater weight loss is difficult to maintain for an extended time. Several available diet plans, consistent with improving overall health, can help your clients achieve their personal goals. On the other hand, there are a good number of diet plans that sound too good to be true, and they probably are.

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Condensed Version and Bottom Line

Healthy weight loss includes moderate calorie restriction emphasizing whole grains, fruits, and vegetables in the diet, along with a physically active lifestyle. Characteristics of successful dieters include eating a low-fat, high-carbohydrate diet, monitoring calorie intake on a regular basis, watching portion sizes, eating breakfast daily, and being physically active every day.

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References

1. Bray, G.A., and B.M. Popkin. Dietary fat intake does affect obesity! American Journal of Clinical Nutrition 68:1157-1173, 1998.
2. Carmichael, H.E., B.A. Swinburn, and M.R. Wilson. Lower fat intake as a predictor of initial and sustained weight loss in obese subjects consuming an otherwise ad libitum diet. Journal of the American Dietetic Association 98:35-39, 1998.
3. Poppitt, S.D., and D.L. Swann. Dietary manipulation and energy compensation: does the intermittent use of low-fat items in the diet reduce total energy intake in free-feeding lean men? International Journal of Obesity and Related Metabolic Disorders 22:1024-1031, 1998.
4. Crovetti, R., M. Porrini, A. Santangelo, and G. Testolin. The influence of thermic effect of food on satiety. European Journal of Clinical Nutrition 52:482-488, 1998.
5. Young, L.R., and M. Nestle. Expanding portion sizes in the US marketplace: implications for nutrition counseling. Journal of the American Dietetic Association 103:231-234, 2003.
6. Wyatt, H.R., G.K. Grunwald, C.L. Mosca, et al. Long-term weight loss and breakfast in subjects in the National Weight Control Registry. Obesity Research 10:78-82, 2002.
7. Schlundt, D.G., J.O. Hill, T. Sbrocco, et al. The role of breakfast in the treatment of obesity: a randomized clinical trial. American Journal of Clinical Nutrition 55:645-651, 1992.
8. Willett, W.C. Eat, Drink, and Be Healthy. New York: Free Press,2003.
9. Flegal, K.M., M.D. Carroll, C.L. Ogden, and C.L. Johnson. Prevalence and trends in obesity among US adults, 1999-2000. Journal of the American Medical Association 288:1723-1727, 2002.
10. Mokdad, A.H., J.S. Marks, D.F. Stroup, and J.L. Gerberding. Actual causes of death in the United States, 2000. Journal of the American Medical Association 291:1238-1245, 2004.
11. Lowe, M.R., K. Miller-Kovach, and S. Phelan. Weight-loss maintenance in overweight individuals one to five years following successful completion of a commercial weight loss program. International Journal of Obesity and Related Metabolic Disorders 25:325-331, 2001.
12. Heymsfield, S.B., C.A. van Mierlo, J.C. van der Knaap, et al. Weight management using a meal replacement strategy: meta and pooling analysis from six studies. International Journal of Obesity and Related Metabolic Disorders 27:537-549, 2003.
Keywords:

Weight Management; Successful Weight Loss; Lifestyle Diet Strategies

© 2005 American College of Sports Medicine