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Fat Loss Part 1 – Adherence

The Single Most Important Factor

AIMS

Fat Loss 101 – creating a calorie deficit• Principles vs Methods

What is adherence?

Monitoring adherence & reducing misreporting

Factors that affect adherence

Methods to improve adherence

• And therefore maximise results

For you to enjoy yourself

For you to actually learn/retain this information• And be able to seamlessly apply it

Fat Loss 101

Creating a calorie deficit

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Energy Balance Recap

Energy Balance = Energy Intake vs Energy Output

Bearing in mind that both Energy Intake AND Energy Expenditure are dynamicBearing in mind that both Energy Intake AND Energy Expenditure are dynamic

Energy Expenditure

EnergyIntake

Neutral Energy Balance

Principles vs Methods

The principle of weight loss• ENERGY DEFICIT

The method used to create an energy deficit can be determined by a number of factors but ultimately finding the diet/strategy/intervention that an individual is most likely to adhere to should be a priority• This method may also change/evolve over time

Fat Loss Hierarchy

Ad

her

ence

Energy Balance / Calories

MacronutrientsProtein

CHO

FatSleep

Nutrient Timing

Fibre/Micronutrients

Ergogenic Aids

Meal Frequency

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Body Composition Hierarchy

Ad

her

ence

Energy Balance / Calories

MacronutrientsProtein

CHO

FatSleep

Meal Frequency

Ergogenic Aids

Nutrient Timing

Fibre/ Micronutrients

What is the only time that a diet fails?

When it…• Fails to put someone in an energy deficit

Four reasons this might happen…1. The ‘diet’ doesn’t even attempt to create a deficit

• Pseudoscientific basis

2. The individual does/can not adhere to it

3. The assumed Energy Expenditure is wrong

4. It focuses on Methods rather than Principles

What NOT to focus on…

‘Toxins’ in your fat cells…

The ‘acidity’ of your body…

Your cortisol levels…

How you’re ‘metabolizing food’…

How ‘sluggish’ your liver is...

How ‘leaky’ your gut is…

Your ‘omega 3:6 balance’…

Body piercings…

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Factors you can manipulate for Fat Loss?

Behavioural• Habits

Satiety• Appetite, Feelings of fullness

Energy Levels/Feelings of well-being• Minimising ‘slumps/cravings’

Adherence/Compliance• Motivating and flexible

Muscle Retention/Metabolic Rate• Increased fat loss or reduced negative implications

Non-Adherence

The primary reason people fail

What do we mean by adherence?

“Significant weight loss was observed with any low-carbohydrate or low-fat diet. Weight loss differences

between individual named diets were small”

This supports the practice of recommending any diet that a patient will adhere to in order to lose weight

Future research needs to understand this• Stratification is the only worthy research pursuit now..

Johnston et al. (2014)

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Different types of adherent client

Knowingly adherent achievers

• Highly motivated clients with no food issues

Unknowingly adherent achievers

• People who go gluten-free

• People for whom exercise decreases/energy intake same

Unknowingly adherent non-achievers

• Everyone that has been failed by a disempowering fadE.g. Eat More Exercise Less – Lose Fat

Different types of adherent client cont....

Knowingly adherent non-achievers

• Underestimation of energy intake

• Overestimation of daily activity level

• Overestimation of exercise energy expenditure

• Underestimation of the adaptations to LT dieting

• Inappropriate methods ergo no deficit created e.g. ad lib dieting

• People at the extremes of BMR?

Knowingly adherent to a deficit non-achievers…

• Water retention!

Different types of non-adherent client

Knowingly non-adherent achievers

• Genetic elite

• Never dieted before / lots of weight to lose

Knowingly non-adherent non-achievers

• Not far enough along the RTC continuum

Unknowingly non-adherent non-achievers

• Most people who ‘can’t lose weight’

• The situation that makes you want to do MNU!• Case study day!

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Monitoring Adherence

Encouraging…

Adherence 101

1. Create an environment where someone is the LEAST likely to lie to you….

2. Create an environment where someone is the LEAST likely to report non-adherence…

3. Create an environment where your advice is trusted and respected…

4. MOTIVATE

1. Reducing Misreporting?

Diet someone on the highest kcals possible…• The closer to predicted RMR that you diet some

individuals, the better the results

Obese out-patients put on a weight loss diet

• Energy intake (the diet) was prescribed either by diet history or predicted requirements

Patients following the ‘predicted’ diet received a significantly higher energy prescription• Weight loss was also significantly greater

Frost et al (1991)

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More Kcal = More Weight Loss?

Frost et al (1991)

More Kcal = More Weight Loss?

Do these results defy the rules of thermodynamics?

“Results suggest that a diet prescription with an energy deficit below the estimated energy requirements does not

lead to greater weight loss and probably reduces compliance”

Adherence (Knowingly and Unknowingly)

Changes in NEAT and habits

Frost et al (1991)

2. Reported Non-Adherence

Flexible Dieting – The Toolbox

Bergman-Evans (2006)

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3. Trust

Don’t lie to them to try to control them….

“Stay off excess alcohol, this will help keeptestosterone levels up and maintain and even boost your muscle mass. Make a commitment to stay of excessive alcohol. One session on it

will make three weeks worth of training pointless…”

3. Respect: Do…… Don’t…..

Respect continued…

Carbohydrates at night… adherence

Eat Dinner Like A Pauper

“Players should be careful about what they eat this meal. This means not eating too much and not eating

TOO LATE AT NIGHT (no later than 7.30pm)”

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Factors that Affect Adherence

Physiological and Psychosocial

What factors are important for adherence?

Results

Easy to stick to

Enjoyable/fun

Social support

Fits with lifestyle

Minimise hunger

Motivational

Minimise discomfort

Personal food preferences

Easy to understand/Simple

Extrinsic motivation

A promise/guarantee

Affordable

Clear goals

Flexible

Timeframe

Physiological Factors

Appetite and hunger• Macronutrient composition (protein content)

• Food choices

• Food volume

• Stress

• Sleep

• Exercise

Food variety

Dietary compensation of different foods

Genetics

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Protein – The Major Player

Satiety in one meal - Blom et al. (2006)

and over 24 hours - Lejeun et al. (2006)

Weight Loss with High vs Moderate Protein• Lower spontaneous energy intake

• Thermic Effect of Food - Raben et al. (2003)

Limit Weight Regain/Support Weight Maintenance

Muscle Retention - Metler et el. (2010)

• Particularly beneficial in older/inactive patients

The next thing in macro-nutrition?

“This study found differential adherence by insulin-resistance status only to a LF-diet, not a LC-diet. IR-participants were less likely to adhere and lose weight on a LF-diet compared to insulin-sensitive (IS) participants assigned to the same diet.” - McClain et al, (2013)

(Cornier et al. 2005)

Food Variety

Food variety increases energy intake (Brondel, 2009)

Food variety causes an appetite- stimulating mechanism due to renewed palatability and interest in eating food (Yeoman’s, 2004)

Food variety may delay satiation in relation to a decrease in ‘sensory specific’ satiety (Romer et al. 2006)

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Sugar – is it really the cause of obesity?

“The intake of sugar only contributed 10% to the rise in calorie intake therefore it is not a major contributor to obesity epidemic.”

Alan Aragon, AAUKC (2013)

Sugar addicts? Sugar undermining

adherence?

Although the intake of high-fat and high-sugar food activates mesolimbic reward, gustatory, and oral somatosensory brain regions, contributing to overeating, few studies have examined the relative role of fat and sugar in the activation of these brain regions, which would inform policy, prevention, and treatment interventions designed to reduce obesity

(Stice et al. 2013)

Food Reward

Relative ability of fat and sugar tastes to activate reward, gustatory, and somatosensory regions

“Fat caused greater activation of the caudate and oral somatosensory regions than did sugar, sugar caused

greater activation in the putamen and gustatory regions than did fat. Results imply that sugar more effectively

recruits reward and gustatory regions, suggesting that policy, prevention, and treatment interventions

should prioritize reductions in sugar intake.”

(Stice et al. 2013)

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Whole Fruit vs Fruit Juice

The Lean Group• Highest dietary compensation – 119%

• No significant weight change (0.84 ± 0.53 kg) after consuming the solid fruits and vegetables

Overweight/Obese Group• Lower compensation - 46%

• Significant weight gain during the solid - 1.77 ± 0.32 kg

Houchins et al. (2012)

Beverage Solid

Exercise

Major genetic component! • Some increase appetite with exercise, others don’t

Important implications for client strategy• Individual assessment necessary

Behaviourally can have heightened importance• All or nothing personalities

Obvious benefits of exercise on health and body composition

The role of sleep for adherence

Insufficient sleep during weight loss can:

Reduce the amount of weight lost

• Specifically fat loss

Increase hunger through hormonal disruption

• Reduces leptin and increases ghrelin

Impair glucose tolerance• Even in healthy people

Nedeltcheva et al. (2010): Morrelli et al. (2010)

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Nedeltcheva et al. (2010)

Psychological Factors

Results• The ultimate adherence tool?

Cravings & feelings of deprivation

Emotional eating

Adherence vs Compliance• Shared responsibility

Motivation to adhere• Important to assess this in case of ‘non-achievement’

• E.g. doctors advice for health vs prepping for a bodybuilding show

Hedonic Hunger

Eating for pleasure rather than somatic reasons

Correlated with perceived deprivation

• NOT with caloric intake

People experiencing hedonic hunger are actually experiencing relative deprivation (i.e. relative to what they would like to have eaten) rather than absolute deprivation

(relative to their energy needs for energy balance)

Monteleone (2012)

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Social/Environmental Factors

The impact of dieting on an individual’s social lifevs social life impact on dieting…

Social support available• Weight loss groups

Improving Adherence

Focusing on the physiology

Understand why someone isn’t adhering

Problem solve assumed non-adherence• Take a step back

• Methodical

• Logged

Be self critical, consider your method and guidelines• Don’t be too trusting

• Believe science over dieters…

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Identify WHY someone isn’t adhering first

Is it physiological?• Methods to reduce hunger/appetite

• Reducing food variety

• Methods to manage stress

• Timing and type of exercise

Is it psychological?• Counselling techniques & motivational interviewing

• Methods to manage cravings – behaviour change

• Methods to reduce feelings of deprivation – dietary flexibility

Is it related to social/environmental factors?• Methods to increase flexibility of dieting

• Introduce social support (weight loss groups)

Adherence to an energy deficit is Fat Loss 101

• Any intervention needs to lead to a deficit

Adherence to an effective method is then key

Understand:

• Knowingly vs. Unknowingly Non-Adherent

• Consider appropriate approaches for each

Be willing to adapt your methods

SUMMARY