Weight Management From the Basics and Beyond

1. Weight ManagementFrom the Basics and Beyond By: Jane Becker, RD, LD, CNSD Clinical Dietitian Shriners Hospital for Children, Tampa

2. Objectives • Improved understanding of caloric needs • Review strategies to manage hunger • Why fiber is filling & how does it work • My Favorite teaching tools • Promising research on weight management

3. Why does SB increase risk of Obesity? • A major contributor to obesity is a lack of ambulation, depending upon the location of the spinal lesion. • If there are lower metabolic demands due to less activity, then diet is even more important for weight management.

4. How do caloric needs Differ? • Calorie needs of 5 different subjects Examples: • Child w/ SB who is over weight • Child w/ SB of normal weight • Child w/out SB of normal weight • Adult w/ out SB of normal weight • Adult w/ SB of normal weight

5. Calculating Energy Needs • Approximating energy needs for children w/ SB can depend on their height. • 7 calorie/cm for weight loss • 9-11calories/cm to maintain weight • Adults w/ SB may require half the number of calories/day as an adults w/out SB .

6. 8 y/o Overweight Child w/ SB Height: 43 inches or 109 cm x 7calorie/cm = 763 calories/day • Not much! It is very easy to see why obesity so prevalent. McDonalds Happy Meal: • low fat chocolate milk, cheeseburger and fries provided: Provides:700 calorie • Low fat plain milk, hamburger, apple dippers (w/o caramel sauce): Provides:435 calories

7. 8y/o with Healthy Body Weight • With Spina Bifida • 9-11 calories/cm, with a height of 109cm • Energy needs: 109 cm x 9–11 calories/cm • Range:981-1200 calories/day • Remember for weight loss: 763 calories/day (218 - 437 less calories/day for weight loss)

8. Energy for a Child w/out SB 8 y/o child who is 18.2kg and 109cm (Normal weight). Energy needs: 70 calories x 18.2kg = 1274 calories/day • Range for SB energy needs is fairly similar to normal needs for growth (1,000-1,200 calories/day)

9. Adult Energy Needs • 40 year old female or male w/out SB w/ a BMI <25 (Healthy Weight) • Weight is 60 kg x 35 calories/kg Estimated Energy needs = 2100 calories/day

10. Adult Energy Needs with SB • 40 year old female or male with a BMI <25 (Healthy Weight) • Weight is 60 kg x 35 calories/kg =2100 calories/day / 2 = • Daily needs of 1050 calories/day

11. So What do these calculation Tell Us? • Likely Spina Bifida contributes to few calories burned per day • Be mindful about what to eat and cultivate healthy eating habits • These calculations are only estimations, that may not take into account your unique capabilities and activity level

12. Let’s Dive into Strategies that help Manage Appetite

13. Add Fruit to meals for Increased Satiety • A study was conducted that looked at the affects of eating an apple before a meal. • Subjects who consumed an apple took in 15% less calories than those who didn’t eat an apple. • Subjects who consume apple juice or applesauce, consumed more calorie than the group who ate the apple. (Flood-Obbagy, Rolls, 2009) • These results suggest that solid fruit affects satiety more than pureed fruit or juice, and that eating fruit at the start of a meal can reduce energy intake.

14. Apples are more than just for Teachers Why: • Increased fiber intake, which slows the rate of gastric emptying • Slows the rate at which we eat • Increase the length of meal time • Fewer Calories: • I apple = 80 calories • 1 cup apple juice = 120 calories • ½ cup sweetened apple sauce = 100 calories

15. Try Low Calorie Starters • Evidence suggests starting a meal with a low calorie appetizer like salad or soup leads to fewer calories taken during that meal. • Broth based vegetable soups were shown to decrease caloric intake in meals by 20%, when compared with meals where no soup was served. (Flood, Rolls, 2007) “ Yes, Soup for YOU!”

16. Low Calorie Soups

17. Salads take a Bite out of Hunger • In an article published in the JADA, 2004 concluded that eating a low calorie salad decreases calorie intake for that meal. • 7% decrease for a small salad • 12% decrease for a large salad Be careful with the toppings!!!

18. Tasty Low Calorie Dressings Wish Bone Salad Sprays: Flavors: Italian, Asian, & Balsamic 1 calorie/spray Farmer Boy Greek Salad Dressing 25 calories/serving (At Publix or Sweetbay Grocery Stores)

19. Why do these Starters work? • They increases the volume of the meal. It is thought that these starters effect the appetite through the sensations felt in the mouth, variations in gastric distention, and slowing gastric emptying.

20. Choose Low Calorie Beverages • Calorie containing beverages supply calories faster and do not increase satiety • Calories from beverages add up quickly, especially in hot weather.

21. Sneaky Beverage Calories

22. Drinking 4 x 12 ounce glasses of regular soda or juice/day Likely can contributes ~600 calories/day This is approximately 50-60% of the calories needed for that Healthy Weight 8 year old Child with SB.

23. Fill up on Fruits and Veggies • People usually eat the same volume of food from day to day. • Foods with a high water content, like fruits and veggies, allow for bigger portions and fewer calories. • Eating low-energy-dense foods, such as fruits and veggies, maintain satiety while reducing energy intake.

24. Building A Healthy Plate Meats Veggies Starch

25. What to do if Your child won’t eat vegetables • Involve them in the decision of what veggie to serve at meal times. • Starting a garden increase intake of veggies. • Involve them in the meal preparation • Eat meals together • BE A GOOD ROLE MODEL!!!!!!!

26. Favorite Books for Feeding Children Child of Mine Feeding with Love and Good Sense By: Ellyn Satter MS, RD, CICSW, BCD How to Get you Kid to Eat…But Not too Much

27. How to Increase Fruit and Veggie Intake • Add fresh, frozen, canned veggies to sauces, soups, and frozen dinner. • Bulk up recipes w/ shredded and diced veggies • Serve frozen fruits like melon and grapes for desserts • Fruits for snacks and desserts

28. Don’t Skip Meals • Those who skip breakfast are likely to weigh more & make up for missed calories, and then some, later in the day. • Missed meals increases appetite and leads to a binge-eating behavior, which is though to improve the bodies ability to store fat.

29. Fiber helps keep you Full

30. How? • It increases chewing, which decreases intake by promoting secretions of saliva and gastric juices, resulting in stomach expansion and increased satiety. • Reduces the absorption efficiency of the small intestine

31. Fiber promotes weight loss • In a 2001 research summary published in Nutrition Reviews, researchers found that in diets where calories were not restricted, and where dietary fiber was increased by an additional 14 grams/day, a 10% decrease in calorie intake was noted. • Resulting in a ~4 pound weight loss over ~4months.

32. Is the Type of Fiber Important? • Most fruits, veggies, whole grain breads and cereals contain a combination of sources. • Two general types: • Soluble • Insoluble

33. Insoluble Fiber • Stays in the gut longer, to increase fullness • How: it dissolves in water and becomes gelatinous. • Sources: beans, peas, whole grains, potatoes, carrots, broccoli, banana, apples, berries, barley, and oats • Many fruits and veggies contain both sources like plums.

34. Insoluble Fiber • Adds bulk to stool and makes it soft to pass. • Sources: • Nuts, cauliflower, zucchini, whole grains, green beans, wheat, corn, tomatoes and celery • Usually the skin of many fruits and veggies provide the soluble fiber.

35. Identifying Good Sources of Fiber • 3 grams is considered a GOOD source of fiber • 5 grams or more is considered a HIGHsource of fiber

36. Food Label Cheat Sheet • 5% means this is a Low source • 10% could mean it is a Good source, depending on what it is next too • 20% means this is a High source

37. Portion Sizes Matters • Satiety is linked with our view of what is a “normal” portion size • To change this few, measuring out servings is key to change

38. It’s About A Balanced Diet • Look for filling up on lower calorie foods, rather than thinking of dieting as following a high protein, or low carbohydrate diet. • Lean meats and low fat dairy • Fruits & Veggies • Whole grain • Light desserts • Water

39. Snacks • Select the Smallest Bags • Research shows that snack intake increases significantly as the package size increases. • Look for airy Snacks • Rice cakes, Popcorn, & Gold Fish • Snacks that have incorporated air to increase the volume, we tend to consume fewer calories even though a greater amount is eaten.

40. The Jury is Still Out • High Protein Diets • Though research suggests protein affects satiety, more research is still needed. • Animal protein also can provides sources of fat, saturated fat and cholesterol. • Low Glycemic Diet

41. Low-Glycemic Diets • Studies suggest that low-glycemic foods or meals provide increased satiety over high-glycemic meals or foods. • Examples of Low-glycemic foods: beans, berries, dairy products, brown rice, nuts, plums, apples, and veggies. • High-Glycemic foods: sugar sweetened cereals, corn flakes, potatoes, most breads, watermelon, honey, and sports drinks.

42. Low-Glycemic Diets • There is confusion in that many low-glycemic foods are also high in fiber • Is it the fiber or low glycemic nature that produce lower blood sugars after meals and improve satiety.

43. Barbara J. Rolls, PhD • Barbara Rolls, Ph.D., professor and Guthrie Chair of Nutrition at Penn State, is the past president of the Obesity Society and has served on the advisory council to the National Institutes of Health's Institute of Diabetes and Digestive and Kidney Diseases. • She is the author of Volumetrics and numerous academic articles.

44. Questions

45. Jane Becker, RD, LD, CNSD Clinical Dietitian Shriners Hospital for Children, Tampa 12502 USF Pine Dr. Tampa, FL 33612-9411 jbecker@shrinenet.org 813-972-2250

47. Comparison of the effects of aspartame and sucrose on appetite and food intakeAppetite, Volume 11, Supplement 1, 1988, Pages 62-67Barbara J. Rolls, Marion Hetherington, Louise J. Laster • We have studied the effects of consumption of foods sweetened with either sucrose or aspartame on appetite ratings and food intake. Normal weight, non-dieting subjects ate the same amount of high- and low-calorie versions of pudding or jello and despite the resulting difference in caloric intake, showed only a non-significant trend towards compensation in a lunch one or two hours later. There were no significant differences between rated hunger, fullness, desire to eat, the amount subjects wanted to eat, or sensory-specific satiety following the high- and low-calorie foods. Knowing the caloric values of the foods did not influence intake or appetite ratings in that both informed and uninformed subjects responded similarly. Thus in the short term subjects tended to eat a constant amount of a particular food and this volume had a greater effect on appetite ratings and subsequent intake than the calories consumed.

48. Incorporation of air into a snack food reduces energy intakeAppetite, Volume 48, Issue 3, May 2007, Pages 351-358Kathrin M. Osterholt, Liane S. Roe, Barbara J. Rolls • Abstract • This study investigated how the air content of a familiar snack food affected energy intake and whether varying the method of serving the snack modified intake. We tested two versions of an extruded snack (cheese puffs) that were equal in energy density (5.7 kcal/g), but differed in energy per volume (less-aerated snack: 1.00 kcal/ml; more-aerated snack: 0.45 kcal/ml). In a within-subjects design, 16 women and 12 men consumed the snacks ad libitum in the laboratory during four afternoon sessions. A standard volume (1250 ml) of each snack was served once in a bowl and once in an opaque bag. Results showed significant differences in intake of the two snacks by energy (p=0.0003) and volume (p<0.0001); subjects consumed 21% less weight and energy (70±17 kcal) of the more-aerated snack than the less-aerated snack, although they consumed a 73% greater volume of the more-aerated snack (239±24 ml). These findings suggest that subjects responded to both the weight and volume of the snack. Despite differences in intake, hunger and fullness ratings did not differ across conditions. The serving method did not significantly affect intake. Results from this study indicate that incorporating air into food provides a strategy to reduce energy intake from energy-dense snacks.

49. The effect of fruit in different forms on energy intake and satiety at a mealAppetite, Volume 52, Issue 2, April 2009, Pages 416-422Julie E. Flood-Obbagy, Barbara J. Rolls • Consuming whole fruit reduces ratings of satiety more than fruit juice, but little is known about the effects of different forms of fruit on subsequent energy intake. This study tested how consuming preloads of apples in different forms prior to a meal (apple, applesauce, and apple juice with and without added fiber) influences satiety and energy intake at meal. Preloads were matched for weight, energy content, energy density, and ingestion rate. Once a week for 5 weeks, 58 adults consumed one of four preloads (266 g; 125 kcal [523 kJ]), or no preload (control), followed by a test meal consumed ad libitum 15 min later. Results showed that eating apple reduced lunch energy intake (preload + test meal) by 15% (187 ± 36 kcal [782 ± 151 kJ]) compared to control (p < 0.0001) and decreased energy intake compared to applesauce and both juices. Fullness ratings differed significantly after preload consumption (apple > applesauce > both juices > control). Overall, whole apple increased satiety more than applesauce or apple juice. Adding naturally occurring levels of fiber to juice did not enhance satiety. These results suggest that solid fruit affects satiety more than pureed fruit or juice, and that eating fruit at the start of a meal can reduce energy intake.

50. Does the consumption of caloric and non-caloric beverages with a meal affect energy intake?Appetite, Volume 44, Issue 2, April 2005, Pages 187-193Diane M. DellaValle, Liane S. Roe, Barbara J. Rolls • Abstract • Beverages are frequently consumed with meals, but their influence on meal energy intake is not understood. We hypothesized that differences in the energy, nutrient content, and sensory properties of beverages consumed with a meal would affect intake. Forty-four women ate lunch in the laboratory once a week for 6 weeks. Lunch was consumed ad libitum, and was served with one of five beverages that were consumed in full, or no beverage. The beverages were 360 g of water, diet cola, regular cola, orange juice, and 1% milk. Results showed an effect of beverage type on meal intake (p<0.0001). Energy intake did not differ among the non-caloric and no-beverage conditions. Similarly, energy intake from lunch (including beverage) did not differ among the caloric beverage conditions. When a caloric beverage (156 kcal; 653 kJ) was consumed with the meal, energy intake was 104±16 kcal (435±67 kJ) greater than when a non-caloric beverage or no beverage was consumed. Subjects' ratings of fullness after lunch did not differ among the beverage conditions, but were lower for the no-beverage condition. These results show that when caloric beverages are consumed with a meal they add to energy intake from food, without significantly affecting satiety ratings.