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Errors in patient perception of caloric deficit required for weight loss—observations from the Diet Plate Trial*
Abstract
Persons with obesity may be poor estimators of caloric content of food. Health care professionals encourage patients to consult nutritional labels as one strategy to assess and restrict caloric intake. Among subjects enrolled in a weight loss clinical trial, the objective is to determine the accuracy of subjects' estimates of caloric deficit needed to achieve the desired weight loss. A 6-month controlled trial demonstrated efficacy of a portion control tool to induce weight loss in 130 obese people with type 2 diabetes. All subjects had previously received dietary teaching from a dietician and a nurse. At baseline, patients were asked how much weight they would like to lose and to quantitatively estimate the caloric deficit required to achieve this weight loss. The stated amount of weight loss desired ranged from 4.5 to 73 kg, with an average of 26.6 kg (n = 127 respondents). Only 30% of participants were willing to estimate the required caloric deficit to lose their target weight. Subjects' per kilograms estimate of caloric deficit required ranged from 0.7 to 2,000,000 calories/kg with a median of 86 calories/kg. Nearly half of subjects (47.4%) underestimated the total required caloric deficit to achieve their target weight loss by greater than 100,000 calories. Despite attendance at a diabetes education centre, this population of obese individuals had a poor understanding of the quantitative relationship between caloric deficit and weight loss. Educational initiatives focused upon quantitative caloric intake and its impact on weight change may be needed to assist obese patients in setting appropriate weight loss goals and achieving the appropriate daily caloric restriction required for success.
... Also, health literacy has been linked to nutrition behavior, portion size estimation, self-care behaviors and healthy eating index [16][17][18][19][20]. An appropriate level of health literacy is likely to be associated with a desired nutrition outcome. ...
The purpose of this study was to examine the conceptual gap between self-perceived weight and body mass index (BMI), and to assess the knowledge gap between perceived importance of following dietary guidelines and health literacy levels. Adults (n = 131) eligible for the Supplemental Nutrition Assistance Program (SNAP) were interviewed at eleven SNAP regional offices in Maryland. Based on BMI calculated from self-reported height and weight, 65.6 % of participants were overweight or obese while 40.5 % perceived that they were overweight or obese. In sub-group analysis categorized by BMI, only 20.0 % in the overweight and 20.0 % in the obese group correctly perceived themselves as being overweight or obese. Following dietary guidelines was perceived as important by a majority of participants, but only 43.5 % had adequate health literacy. Conceptual and knowledge gaps between self-perception and objective health status existed in the low-income SNAP-eligible sample. Future studies need to address these gaps because misperceived weight status and insufficient health literacy are critical barriers to inducing behavioral change.
... Also, health literacy has been linked to nutrition behavior, portion size estimation, self-care behaviors and healthy eating index [16][17][18][19][20]. An appropriate level of health literacy is likely to be associated with a desired nutrition outcome. ...
The purpose of this study was to examine the conceptual gap between self-perceived weight and body mass index (BMI), and to assess the knowledge gap between perceived importance of following dietary guidelines and health literacy levels. Adults (n = 131) eligible for the Supplemental Nutrition Assistance Program (SNAP) were interviewed at eleven SNAP regional offices in Maryland. Based on BMI calculated from self-reported height and weight, 65.6 % of participants were overweight or obese while 40.5 % perceived that they were overweight or obese. In subgroup analysis categorized by BMI, only 20.0 % in the overweight and 20.0 % in the obese group correctly perceived themselves as being overweight or obese. Following dietary guidelines was perceived as important by a majority of participants, but only 43.5 % had adequate health literacy. Conceptual and knowledge gaps between self-perception and objective health status existed in the low-income SNAP-eligible sample. Future studies need to address these gaps because misperceived weight status and insufficient health literacy are critical barriers to inducing behavioral change.
Wstęp: W środowisku pacjentów chorych na cukrzycę krąży wiele mitów dotyczących produktów spożywczych, które mają obniżać poziom glukozy we krwi lub przynajmniej go nie podnosić. Celem badania było zbadanie stanu wiedzy na temat wpływu popularnych i często stosowanych produktów spożywczych na poziom glikemii wśród chorych na cukrzycę oraz wśród pielęgniarek zatrudnionych w szpitalach.Materiały i metody: Grupa badana obejmowała 250 chorych na cukrzycę (DM), członków Polskiego Stowarzyszenia Diabetyków, oraz grupę kontrolną 123 zdrowych pielęgniarek (N) z 3 szczecińskich szpitali. Badanych poproszono o wypeł- nienie ankiety weryϐikującej ich wiedzę na temat wpływu na glikemię produktów spożywczych często stosowanych w diecie cukrzycowej (grejpfrut, miód, kawa zbożowa, czekolada dla diabetyków, zupa mleczna z płatkami oraz karkówka).Wyniki: Najwięcej błędnych odpowiedzi, zarówno wśród chorych, jak i personelu, zostało zaznaczonych w przypadku karkówki (DM 71%; N 83%, NS) oraz grejpfruta (DM 51%; N 77%, p < 0,01). Najwięcej prawidłowych odpowiedzi pojawiło się w przypadku miodu (DM 69%; N 80%, p < 0,05) oraz zupy mlecznej (DM 64%; N 67%, NS). Wykazano negatywną korelację między liczbą poprawnych odpowiedzi a wiekiem pacjentów (rs = −0,14, p < 0,01). Czas trwania cukrzycy nie miał wpływu na poziom wiedzy pacjentów z zakresu wpływu wybranych produktów spożywczych na poziom glikemii. Chorzy leczeni insuliną stosowaną mieli wyższy poziom wiedzy niż osoby stosujące leki doustne (44% vs 34, 8%, p < 0,01).Wnioski: 1. Poziom edukacji pacjentów oraz personelu średniego szpitala z zakresu wpływu popularnych produktów na glikemię chorego jest niski. 2. Zarówno chorzy na cukrzycę, jak i pielę- gniarki zatrudnione w szpitalach wymagają edukacji z zakresu diety cukrzycowej.
Background:
The possible advantage for weight loss of a diet that emphasizes protein, fat, or carbohydrates has not been established, and there are few studies that extend beyond 1 year.
Methods:
We randomly assigned 811 overweight adults to one of four diets; the targeted percentages of energy derived from fat, protein, and carbohydrates in the four diets were 20, 15, and 65%; 20, 25, and 55%; 40, 15, and 45%; and 40, 25, and 35%. The diets consisted of similar foods and met guidelines for cardiovascular health. The participants were offered group and individual instructional sessions for 2 years. The primary outcome was the change in body weight after 2 years in two-by-two factorial comparisons of low fat versus high fat and average protein versus high protein and in the comparison of highest and lowest carbohydrate content.
Results:
At 6 months, participants assigned to each diet had lost an average of 6 kg, which represented 7% of their initial weight; they began to regain weight after 12 months. By 2 years, weight loss remained similar in those who were assigned to a diet with 15% protein and those assigned to a diet with 25% protein (3.0 and 3.6 kg, respectively); in those assigned to a diet with 20% fat and those assigned to a diet with 40% fat (3.3 kg for both groups); and in those assigned to a diet with 65% carbohydrates and those assigned to a diet with 35% carbohydrates (2.9 and 3.4 kg, respectively) (P>0.20 for all comparisons). Among the 80% of participants who completed the trial, the average weight loss was 4 kg; 14 to 15% of the participants had a reduction of at least 10% of their initial body weight. Satiety, hunger, satisfaction with the diet, and attendance at group sessions were similar for all diets; attendance was strongly associated with weight loss (0.2 kg per session attended). The diets improved lipid-related risk factors and fasting insulin levels.
Conclusions:
Reduced-calorie diets result in clinically meaningful weight loss regardless of which macronutrients they emphasize. (ClinicalTrials.gov number, NCT00072995.)
Portion size is an important determinant of energy intake. To our knowledge, no randomized controlled trial has evaluated the efficacy of portion control tools to induce weight loss. In patients with type 2 diabetes mellitus, weight reduction improves glycemic control.
We randomly assigned 130 obese patients with type 2 diabetes mellitus (including 55 patients taking insulin) to the daily use of a commercially available portion control plate for 6 months (intervention group) vs to usual care in the form of dietary teaching (usual care control group).
Follow-up was 93.8%. Patients in the intervention group lost significantly more weight than control subjects (mean+/-SD, 1.8%+/-3.9% vs 0.1%+/-3.0%, P=.006). Compared with controls, more patients in the intervention group required a decrease in their diabetes medications at 6 months (26.2% vs 10.8%, P=.04).
Compared with usual care, the portion control tool studied was effective in inducing weight loss. The portion control plate also enabled patients with diabetes mellitus to decrease their hypoglycemic medications without sacrificing glycemic control.
clinicaltrials.gov Identifier: NCT00254124.
Dietary and lifestyle modification efforts are the primary treatments for people who are obese or overweight. The effect of dietary counseling on long-term weight change is unclear.
To perform a meta-analysis of the effect of dietary counseling compared with usual care on body mass index (BMI) over time in adults.
Early studies (1980 through 1997) from a previously published systematic review; MEDLINE and the Cochrane Central Register of Controlled Trials from 1997 through July 2006.
English-language randomized, controlled trials (> or =16 weeks in duration) in overweight adults that reported the effect of dietary counseling on weight. The authors included only weight loss studies with a dietary component.
Single reviewers performed full data extraction; at least 1 additional reviewer reviewed the data.
Random-effects model meta-analyses of 46 trials of dietary counseling revealed a maximum net treatment effect of -1.9 (95% CI, -2.3 to -1.5) BMI units (approximately -6%) at 12 months. Meta-analysis of changes in weight over time (slopes) and meta-regression suggest a change of approximately -0.1 BMI unit per month from 3 to 12 months of active programs and a regain of approximately 0.02 to 0.03 BMI unit per month during subsequent maintenance phases. Different analyses suggested that calorie recommendations, frequency of support meetings, inclusion of exercise, and diabetes may be independent predictors of weight change.
The interventions, study samples, and weight changes were heterogeneous. Studies were generally of moderate to poor methodological quality. They had high rates of missing data and failed to explain these losses. The meta-analytic techniques could not fully account for these limitations.
Compared with usual care, dietary counseling interventions produce modest weight losses that diminish over time. In future studies, minimizing loss to follow-up and determining which factors result in more effective weight loss should be emphasized.
Medical nutrition therapy (MNT) is important in preventing diabetes, managing existing diabetes, and preventing, or at least slowing, the rate of development of diabetes complications. It is, therefore, important at all levels of diabetes prevention. MNT is also an integral component of diabetes self-management education (or training). This position statement provides evidence-based recommendations and interventions for diabetes MNT. The previous position statement with accompanying technical review was published in 2002 and modified slightly in 2004. This statement updates previous position statements, focuses on key references published since the year 2000, and uses grading according to the level of evidence available...
This statement summarizes the U.S. Preventive Services Task Force (USPSTF) recommendations on screening for obesity in adults based on the USPSTF's examination of evidence specific to obesity and overweight in adults and updates the 1996 recommendations on this topic. The complete USPSTF recommendation and rationale statement on this topic, which includes a brief review of the supporting evidence, is available through the USPSTF Web site (www.preventiveservices.gov), the National Guideline Clearinghouse (www.guideline.gov), and in print through the Agency for Healthcare Research and Quality Publications Clearinghouse (telephone, 800-358-9295; e-mail, ahrqpubs@ahrq.gov). The complete information on which this statement is based, including evidence tables and references, is available in the accompanying article in this issue and in the summary of the evidence and systematic evidence review on the Web sites already mentioned. The summary of the evidence is also available in print through the Agency for Healthcare Research and Quality Publications Clearinghouse.
BACKGROUND: Commentators have suggested that patients may understand quantitative information about treatment benefits better when they are presented as numbers needed to treat (NNT) rather than as absolute or relative risk reductions.
OBJECTIVE: To determine whether NNT helps patients interpret treatment benefits better than absolute risk reduction (ARR), relative risk reduction (RRR), or a combination of all three of these risk reduction presentations (COMBO).
DESIGN: Randomized cross-sectional survey.
SETTING: University internal medicine clinic.
PATIENTS: Three hundred fifty-seven men and women, ages 50 to 80, who presented for health care.
INTERVENTIONS: Subjects were given written information about the baseline risk of a hypothetical “disease Y” and were asked (1) to compare the benefits of two drug treatments for disease Y, stating which provided more benefit; and (2) to calculate the effect of one of those drug treatments on a given baseline risk of disease. Risk information was presented to each subject in one of four randomly allocated risk formats: NNT, ARR, RRR, or COMBO.
MAIN RESULTS: When asked to state which of two treatments provided more benefit, subjects who received the RRR format responded correctly most often (60% correct vs 43% for COMBO, 42% for ARR, and 30% for NNT, P=.001). Most subjects were unable to calculate the effect of drug treatment on the given baseline risk of disease, although subjects receiving the RRR and ARR formats responded correctly more often (21% and 17% compared to 7% for COMBO and 6% for NNT, P=.004).
CONCLUSION: Patients are best able to interpret the benefits of treatment when they are presented in an RRR format with a given baseline risk of disease. ARR also is easily interpreted. NNT is often misinterpreted by patients and should not be used alone to communicate risk to patients.
In an attempt to replicate and extend previous research on the validity of food diaries, 43 obese females were quizzed on food recording and calorie estimation in a controlled analogue of self-monitoring. Sources of error were identified that included poor food descriptions, inaccurate quantity estimations, and a variety of computational errors in converting calories. These sources of subject error revealed areas for training in accurate food recording and calorie estimation. The clinical and theoretical importance of establishing the validity of food diaries through accuracy training is emphasized.
We report three studies that examine the accuracy and usefulness of food records among dieting obese patients. In study 1 errors in quantity and calorie estimates for 10 common foods averaged 63.9% (quantity) and 53.4% (calories). The results of study 2 indicate that only 53% of entries in daily food records were specified enough to permit objective estimates of the calories consumed. In study 3, blind raters could not predict weight loss based on subjects' self-recorded behavior changes. Collectively, these results question the utility of food records for estimating energy intake or predicting weight loss.
The Commission on Dietary Supplement Labels encourages nutrition professionals to become knowledgeable about all dietary supplements. The Dietary Supplement Health and Education Act of 1995 (DSHEA) expanded the definition of dietary supplements beyond essential nutrients while distinguishing them from drugs or food additives. In order to give practical advice to consumers and policymakers, dietetics professionals need to understand the implications resulting from this less-restrictive regulatory environment for supplements. Dietetics professionals must also become familiar with claims made by manufacturers, retailers, and others regarding popular nonvitamin, nonmineral (NVNM) supplements, as well as usage prevalence and trends. However, NVNM supplements currently are classified inconsistently, and information on the prevalence of use is limited. Sales data suggest that total intake is increasing, and garlic and ginseng are consistently among the most popular supplements. Reported use of NVNM supplements in the third National Health and Nutrition Examination Survey was highest for garlic and lecithin. The data suggest associations of NVNM supplement use with age and more healthful lifestyles; however, there is also a reported link with higher alcohol consumption and obesity. Associations with education, income, region, and urbanization are not evident from the sales data. Standardized survey procedures regarding question phraseology, referent time period, and supplement categorization--along with use of representative samples--will improve our ability to assess supplement use, prevalence, and trends.
Obesity is a worldwide epidemic and will be followed by a worldwide
epidemic of diabetes.1 While diet, lifestyle,
and exercise are the cornerstones of current approaches to treat obesity,
they have been ineffective in stemming the current epidemic. In this issue
of THE JOURNAL, the article by Bravata et al2 systematically
reviews and synthesizes the literature on the use of low-carbohydrate diets
for treatment of obesity. Their findings add to the review of popular diets
published by Freedman et al.3 Among the principal
findings in the analysis by Bravata et al are that lower-carbohydrate (≤60
g/d of carbohydrate) diets were associated with reduced calorie intake and
that weight loss was predicted by calorie intake, diet duration, and baseline
body weight, but not by carbohydrate content. At the end of their analysis,
Bravata et al note several gaps in the current literature on low-carbohydrate
diets, including the need for better follow-up and for use of intent-to-treat
analyses.
To the Editor:—
The article by Dr. W. L. Bloom entitled "Fasting as an Introduction to the Treatment of Obesity" (Metabolism8:214 [May] 1959) which was summarized in The Journal, Jan. 23, page 328, prompts me to say that the subject of caloric equivalents of gained or lost weight under varying conditions has hardly been explored by workers in the field of metabolism. Knowledge of the following facts is essential. Carbohydrate and protein cannot be stored dry but retain with them three or more parts of water, while fat can be stored in an almost pure state. One gram of adipose tissue gives the body 8.3 calories of reserve energy, while retention of 1 Gm. of water-soaked glycogen or protein provides only about one calorie. These factors are basic for the determination of the caloric equivalents of gained or lost weight.The average obese patient who is placed on
Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association
- American Diabetes Association