Myth #3 from NEJM article Feb 2013

4 points about rapid weight loss



POINT ONE:

"Hefty, rapid weight is linked with poorer long-term outcomes than gradual weight loss"

"The above myth arose in reaction to adverse effects of very low calorie less than 800 calorie per day.

"Within weight-loss trials, more rapid and

greater initial weight loss has been associated

with lower body weight at the end of long-term

follow-up.

9,10

A meta-analysis of randomized,

controlled trials that compared rapid weight loss

(achieved with very-low-energy diets) with slower

weight loss (achieved with low-energy diets —

i.e., 800 to 1200 kcal per day) at the end of short-

term follow-up

(≥1 year) showed that, despite the association of

very-low-energy diets with significantly greater

weight loss at the end of short-term follow-up

(16.1% of body weight lost, vs. 9.7% with low-

energy diets), there was no significant difference

between the very-low-energy diets and low-energy

diets with respect to weight loss at the end of

long-term follow-up.

10

Although it is not clear

why some obese persons have a greater initial

weight loss than others do, a recommendation

to lose weight more slowly might interfere with

the ultimate success of weight-loss efforts."

 
http://www.nejm.org/doi/full/10.1056/NEJMsa1208051 link


 
POINT TWO:

Look Ahead data shows those who lost more wt maintained more wt loss link
from
Obesity (Silver Spring). 2015 Jul;23(7):1353-6. doi: 10.1002/oby.21112.



POINT THREE:


The usual concern about losing weight rapidly is that a great deal of muscle is lost as well as fat as this article below shows.

"The healthiest way to lose one to two pounds per week is to eat about 1,500 calories per day if you're female, or about 2,000 calories per day if you're male.

This will help ensure adequate nutrition while still allowing you to easily burn more calories than you eat each day, which is how you lose weight.

Even with a sensible eating plan, however, you may lose muscle mass without working out."

The rest of the article is at Nina Kate's article 


POINT FOUR

 2013 High Protein diet during wt loss may decrease fat free mass loss link to article

"In summary, we determined that consuming dietary protein at levels exceeding the RDA may protect fat-free mass during short-term weight loss."

 

 

The Three Treatments of Obestiy

Again from Handbook of Obesity Edited by Bray and Brouchard Vol. 2 p 397-398 written by Lars Sjostrom:

Conclusions

“As illustrated by the conventionally treated obese control group of SOS, nonpharmacological obesity treatment at primary health-care centers is not, on average, associated with any weight loss in the short or long term.”

“Treatment with currently available antiobesity drugs typically results in 7-10% weight reduction over 2-4 years as compared to 4% to 6% in placebo/lifestyle groups.”

“Reports from SOS trial have demonstrated that sustained positive effects on risk factors over 10 years require persistent weight loss in the range of 10% to 30%.”

“Obese patients with prediabetes and T2D deserve extra attention.
 It is more difficult to achieve conventional or pharmacologically induced weight loss in diabetic obese patients.
Moreover, even when weight loss is achieved almost all patients relapse within a few years. Treatment with sulphonylureas or insulin causes weight gain.
 Thus, obesity not only causes diabetes but is also a complication of diabetes treatment with some medications.
This vicious spiral must be broken for a successful management of T2D.”

“Surgery is the only treatment of obesity resulting, on average, in more than 15% documented weight loss over 10 years.”

My comment in purple:
Orlistat was used in Look Ahead trial link

Graph showing weight loss over 10 years in Look Ahead link


The mantra taught at NY Presbyterian/Columbia College of Physicians course on Obesity in April 2015 was that providers should be satisfied with 5-8% weight loss reduction as it tends to improve risk factors. 

Now that I have read the above text I wonder at the false hope that is presented. 

The good news is that Qsymia (phentermine/topiramate ER) maintained a weight loss of 10.7% from baseline after two years in the SEQUEL study.

Weight loss with diet and medicine not yet shown to improved mortality? Bariatric surgery has.

I am studying the Handbook of Obesity for my Obesity Boards in Dec 2015.  It is edited by Bray and Bouchard.

In Vol. 2 Fourth edition p385-386 are the following excerpts:

“However with the the exception for the Swedish Obese Subjects (SOS) trial, controlled interventional studies demonstrating that weight loss is in fact reducing mortality have been lacking”

“To date most observational epidemiological studies have indicated that overall and cardiovascular mortality is increased after weight loss even in subjects who were overweight or obese at baseline.”

“...the observed weight loss might be the consequence of conditions that lead to death rather than the cause of death.”

“Lifestyle interventions to protect against diabetes have not prevented cardiovascular events after 10-20 years of follow up.”

References:

24-Yaari. Voluntary Wt. loss. Am J Epidemiol 1998: 148: 546-555

25- Wannamethee. Older men who lose weight. Am J Epidemiol 2000; 151:667-75

26- Li G. Long term-effect of life-style interventions. Lancet 2008;371: 1783-9

27- Uusitupa. Morbidity in Finnish Diabetes Prevention Study. PLoS One 2009; 4e5656

28- Nissen SE. Rimonabant in STRADIVARIUS TRIAL. JAMA 2008; 299 1547-60

NLA has individualized guidelines for statin therapy.

High dose statin should be last step in combo therapy link



My comment:

Many patients have been lost to statins because of failure to avoid side effects at high doses.  

My opinion is to use lowest dose first as there is a variability of response (as noted above).  

Individualize therapy with goal of compliance being equally important to goal of LDLp < 750 to 1,000. 

Adding low dose(1,000 mg)  Slo-niacin or Endur-acin is very inexpensive and has additive effect of lowering LDLp better than higher dose of statin. If we are to treat earlier and for longer periods we need to use lowest effective dose at lowest price with least side effects.  

REE is lower than expected after weight loss from surgery

Dr. Gallagher shows surprising result in REE after surgery link to 1 min 17 sec video





Dr. Dympna Gallagher shows that REE reduces more in weight loss than  can be explained.

Fat Free Mass(FFM) of 60 to 50 should just move REE down same(red) line but it moves to lower lines(Green & Blue).  "Which is something that is well noted in EE studies,  that when people loss weight the REE decreases to a greater extent than can be explained by the decrease in FFM. "


"Resting Energy Expenditure (REE) is largely mediated by your body composition."

Graph in photo below shows REE as a function of FFM (fat free mass) before surgery (red line), one year later (green line) two years later (blue line)

Sponge Syndrome discussed at Obesity Board Review 2015

Sponge Syndrome link


Dr. Gallagher answers question about large number of fat cells 
 link to 1 min 43 sec video above



I asked Dr. Dympna Gallagher about the number of fat cells before and after gastric bypass not being changed by 32% weight loss.  Those million of cells are always there ready to take on lipids at a low calorie level.

Do Statins cause cancer by lowering LDLc?

2012 Meta-analysis  link


Need to look at overall mortality- Statins good for this link to original letter and rebuttal



I respect Uffe Ravnskov and his recent letter about colon-cancer contained an impressive list of random controlled trials.

I include in this blog the authors rebuttal to Ravnskov but I felt I could look up the specific trials and find out what the total mortality was. Cancer cachexia will have low LDLc. Suicides also occur. This is why it is important to look at total mortality. 4S trial and HPS did this.

4S trial results
"The Scandinavian Simvastatin Survival Study (4S trial) randomized 4444 patients with acute coronary syndromes to simvastatin versus placebo. All-cause mortality, fatal coronary events and coronary revascularization procedures were reduced in the simvastatin group. This was regardless of the baseline HDL or LDL cholesterol levels."

HPS on wiki
"The number needed to treat in the study was 57 patients to postpone one death and 19 to prevent one cardiovascular "event" (in those taking the drug simvastatin for 5 years). There was no mortality benefit in women. Cancer risk was suggestively lower in the treatment group. No worsening of lung disease was found, an initial concern with statin drugs, and simvastatin did not decrease osteoporosis."

Statins have been given to millions of people since 1987. To my knowledge there is no association of a surge of cancer?

Ravnskov states the lower the LDLc the more the chance of cancer. In JUPITER, LDLc were as low as 35 to 55 but no increased mortality.

WATERFALL RESULTS IN DIET TRIALS

1: ATOZ TRIAL

Results of best trial comparing diets 1 min 22 sec clip



Circled area on graph shows that all 4 diets had 30 lb. plus weight loss that lasted for a year. The right side of graph shows how many of the 300 people gained weight in the ATOZ trial.

 2-GASTRIC BYPASS WATERFALL RESULTS

Waterfall variability after Gastric Bypass
Notice 5-9 increase after 6 years



3- WATERFALL RESULT OF 8 YEAR LOOK AHEAD TRAIL

 
4-WATERFALL RESULT OF CONTROL & ILI

          ARM OF LOOK AHEAD TRIAL
     

Science trials variability of results in a chart

Dr. Weil said his program has 8% that don't lose any weight 
50 sec link above.



Richard Weil, M.Ed., CDE gave a lecture at a Obesity Board review course where he said all studies have this variability of results.  This trial had 35 participants.  Mr Weil says his program for weight loss (which is one of the best in the country) with a multidisciplinary approach has the same results with it's 600 participants.  8% of his patients don't lose weight.

Look Ahead Trial as per Dr. Gary Foster

Look Ahead Trial 50 second video

SEE SUPER ACHIEVERS LINK


Dr. Gary Foster's lecture at Obesity Review Course in April 2015


"This is the best science available taken from places across the country who are good at implementing it."

"This shows that you can get good weight loss with behavioral change"

"3.6 delta" (weight loss % change from control) after 4 years.

My comment:
After the lecture I asked Dr. Foster if Orlistat was used in the treatment arm.  He said yes, but he didn't think it was much.

My research    showed this:

Orlistat used to lose weight in intervention arm. (ILI)

Orlistat is a weight loss drug.

Go to page 31 in supplement on drugs. 10% use in year one Orlistat 8% wt. loss

As Orlistat use decreased in yrs. 2, 3 and 4, the weight lost % went down.

Others blogs on Look Ahead:

http://www.healthcommunities.com/diabetes-management/secrets-to-maintain-weight-loss_jhmwp.shtml

2-NEJM Look Ahead Lifetsyle changes with negative outcome

The LOOK AHEAD trial failed in its primary outcome NEJM July 11, 2013.
However secondary outcomes at 5% weight loss  were good.  2014 Dec  Pi-Sunyer X1.

The LOOK AHEAD trial is one of the longest diet studies on record. 

2-39%  > 10% weight loss 4 eight years in Look Ahead 


However, then you look at the control results (DSE).
24% of the control group lost more than 10% of weight after 8 years.  WOW! 
 This is called the Waterfall result in diet trials.

Weight Loss expectations Part 2

Dr. Gary Foster talks about helping people accept smaller weight loss expectations. 






Modest weight loss expectations 3 minute video

Most people who go on diet hope to lose 32% of weight

Part One

Unrealistic expectations of weight loss 1 min 50 sec video


Dr. Gary Foster from Weight Watchers says in past people hoped to lose 32% of weight.
Recently he polled 300 people and the expectation had dropped to 19% weight loss.  Still very high.

In this 48 week trial people lost 16 kg.
"They had to lose 5 more pounds just to be disappointed in their weight loss."

How much exercise to prolong life. Nice article by Gretchen Reynolds

2 Big studies confirm 20 mins good but 60 mins better. Link


JAMA STUDY:

"But those who exercised a little, not meeting the recommendations but doing something, lowered their risk of premature death by 20 percent.

Those who met the guidelines precisely, completing 150 minutes per week of moderate exercise, enjoyed greater longevity benefits and 31 percent less risk of dying during the 14-year period compared with those who never exercised.

The sweet spot for exercise benefits, however, came among those who tripled the recommended level of exercise, working out moderately, mostly by walking, for 450 minutes per week, or a little more than an hour per day. Those people were 39 percent less likely to die prematurely than people who never exercised.

At that point, the benefits plateaued, the researchers found, but they never significantly declined."

AUSTRALIAN STUDY:
Anyone who is physically capable of activity should try to “reach at least 150 minutes of physical activity per week and have around 20 to 30 minutes of that be vigorous activity,” 

HDL's shown to play cardioprotective role

 Link below here:
"This conclusion strengthens the case that at least one of the cardioprotective functions of HDLs is a predictor of cardiovascular events. "



"This study showed an inverse association of cholesterol efflux capacity and HDL particle concentration, but not HDL cholesterol concentration, with incident cardiovascular events."

"Furthermore, because there were few events in the Dallas Heart Study, it was important that the findings were confirmed in an independent cohort, using radiolabelled cholesterol to assess cholesterol efflux capacity.

Such a study is reported in The Lancet Diabetes & Endocrinology, in which radiolabelled cholesterol was used to measure the cholesterol efflux capacity of apoB-depleted serum in a prospective investigation of 1745 patients with incident coronary heart disease and 1749 healthy controls from the EPIC-Norfolk study.10'

Saleheen, D, Scott, R, Javad, S et al. Association of HDL cholesterol efflux capacity with incident CHD events: a prospective case control study. Lancet Diabetes Endocrinol. 2015; (published online May 27.)http://dx.doi.org/10.1016/S2213-8587(15)00126-6.

Also http://m.circ.ahajournals.org/content/130/Suppl_2/A12252.abstract?related-urls=yes&legid=circulationaha%3b130/Suppl_2/A12252