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Ötüken Köroğlu Y, Öztürk M. Meal Frequency Does Not Affect Weight Loss in Overweight/Obese Women but Affects the Body Composition: A Randomized Controlled Trial. JOURNAL OF THE AMERICAN NUTRITION ASSOCIATION 2024:1-9. [PMID: 38349951 DOI: 10.1080/27697061.2024.2316636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 02/04/2024] [Indexed: 02/15/2024]
Abstract
OBJECTIVES Studies showing the relationship between meal frequency, weight loss and anthropometric measurements are contradictory. This study aims to determine the effect of meal frequency on weight loss, anthropometric measurements, and body composition. METHODS This is a parallel designed randomized control trial that was conducted with 40 female volunteers between the ages of 19-64 years, with a Body Mass Index (BMI) ≥27 who applied to a private clinic. Participants were randomized in two treatment arms (3 meals + 3 snacks/day (n = 20) vs 3 meals/day (n = 20)) and same dietary energy restriction (-500kcal) was applied for 3 months. Food consumption was questioned with 3 day food records, and anthropometric measurements and body composition were measured before the study and repeated each week till the end of the study by the researcher. RESULTS All of the participants completed the study period. Body weight (kg), BMI (kg/m2), total body fat (kg), body fat percentage (%), fat free mass (kg) and waist circumference (cm) decreased, while fat free mass percentage (%) increased significantly in both of the groups at the end of the study (p < 0.05). The rate of difference for body weight, BMI (kg/m2) and waist circumference (cm) were similar among the groups. When difference in body composition analyses was examined, the rate of reduction in total body fat (-18.82 ± 4.97% vs -14.87 ± 7.44%) and body fat percentage (%)(-10.79 ± 4.63% vs -7.68 ± 7.04%) and the rate of increase in fat free mass percentage (%)(7.65 ± 3.16% vs 5.04 ± 3.44%) were significantly higher in 3 meals + 3 snacks group (p < 0.05). CONCLUSION When energy restricted and balanced weight loss programs are applied, alteration in body weight, BMI and waist circumference is not affected from meal frequency, but body composition does. CLINICAL TRIAL NUMBER NCT05581862 (Date of Trial Registration: 13/10/2022).
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Affiliation(s)
- Yazgı Ötüken Köroğlu
- Nutrition and Dietetics Department, Faculty of Health Sciences, Eastern Mediterranean University, Famagusta, Northern Cyprus
| | - Müjgan Öztürk
- Nutrition and Dietetics Department, Faculty of Health Sciences, Eastern Mediterranean University, Famagusta, Northern Cyprus
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Blazey P, Habibi A, Hassen N, Friedman D, Khan KM, Ardern CL. The effects of eating frequency on changes in body composition and cardiometabolic health in adults: a systematic review with meta-analysis of randomized trials. Int J Behav Nutr Phys Act 2023; 20:133. [PMID: 37964316 PMCID: PMC10647044 DOI: 10.1186/s12966-023-01532-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 10/29/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Eating frequency may affect body weight and cardiometabolic health. Intervention trials and observational studies have both indicated that high- and low-frequency eating can be associated with better health outcomes. There are currently no guidelines to inform how to advise healthy adults about how frequently to consume food or beverages. AIM To establish whether restricted- (≤ three meals per day) frequency had a superior effect on markers of cardiometabolic health (primary outcome: weight change) compared to unrestricted-eating (≥ four meals per day) frequency in adults. METHODS We searched Medline (Ovid), Embase, CINAHL (EBSCO), Cochrane Central Register of Controlled Trials (CENTRAL), CAB Direct and Web of Science Core Collection electronic databases from inception to 7 June 2022 for clinical trials (randomised parallel or cross-over trials) reporting on the effect of high or low-frequency eating on cardiometabolic health (primary outcome: weight change). Trial interventions had to last for at least two weeks, and had to have been conducted in human adults. Bias was assessed using the Cochrane Risk of Bias tool 2.0. Standardized mean differences (SMD) and 95% confidence intervals were calculated for all outcomes. Certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS Seventeen reports covering 16 trials were included in the systematic review. Data from five trials were excluded from meta-analysis due to insufficient reporting. 15 of 16 trials were at high risk of bias. There was very low certainty evidence of no difference between high- and low-frequency eating for weight-change (MD: -0.62 kg, CI95: -2.76 to 1.52 kg, p = 0.57). CONCLUSIONS There was no discernible advantage to eating in a high- or low-frequency dietary pattern for cardiometabolic health. We cannot advocate for either restricted- or unrestricted eating frequency to change markers of cardiometabolic health in healthy young to middle-aged adults. PROTOCOL REGISTRATION CRD42019137938.
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Affiliation(s)
- Paul Blazey
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, Canada.
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver Coastal Health Research Institute, Vancouver, Canada.
| | - Alireza Habibi
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Nejat Hassen
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Arthritis Research Canada, Vancouver, BC, Canada
| | - Daniel Friedman
- AIS Medicine, Australian Institute of Sport, Canberra, Australian Capital Territory, Australia
| | - Karim M Khan
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver Coastal Health Research Institute, Vancouver, Canada
- School of Kinesiology, The University of British Columbia, Vancouver, BC, Canada
| | - Clare L Ardern
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver Coastal Health Research Institute, Vancouver, Canada
- Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Australia
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada
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Herrán OF, Herrán-Fonseca C. Meal occasion, overweight, obesity and central obesity in children and adults: a cross-sectional study based on a nationally representative survey. Colombia, 2015. BMJ Open 2022; 12:e064832. [PMID: 36123072 PMCID: PMC9486272 DOI: 10.1136/bmjopen-2022-064832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To establish the association of the number of meals/day with overweight (Ow), obesity (Ob) and central obesity (CO). DESIGN Cross-sectional, nationally representative surveys. SETTING Colombia. PARTICIPANTS A total of 6985 children aged 5-17 years and 7846 adults aged 18-64 years were included. MAIN OUTCOMES AND MEASURES According to the WHO, Ow was defined in children as a body mass index (BMI)-for-age Z-score between >1 and ≤2 and in adults as a BMI between ≥25 and <30 (kg/m2). Ob was defined as a Z-score >2 in children and as a BMI ≥30 in adults. CO in children was established by sex and age using cut-off points equivalent to those of adults established by the International Diabetes Federation: ≥90 and ≥80 cm in males and females, respectively. The number of meals/day was estimated with a Food Frequency Questionnaire. Meals/day were grouped into three categories: (reference ≤3, 4 and 5+ meals/day). Crude and adjusted relative prevalence ratios (PRs) and their 95% CIs were calculated. The adjustments included usual energy intake/day and physical activity. RESULTS In children, 18.5% had Ow, 6.7% had Ob and 4.0% had CO. The adjusted PRs for five or more meals/day versus three or fewer meals/day were 1.10 (95% CI 0.79 to 1.55) for Ow, 0.95 (95% CI 0.57 to 1.59) for Ob and 1.06 (95% CI 0.72 to 1.55) for CO. In adults, 32.3% had Ow, 13.1% had Ob and 44.8% had CO. The adjusted PRs for five or more meals/day versus three or fewer meals/day were 0.58 (95% CI 0.45 to 0.76) for Ow, 0.51 (95% CI 0.36 to 0.72) for Ob and 0.70 (95% CI 0.54 to 0.92) for CO. CONCLUSIONS In children, meals/day were not associated with Ow, Ob or CO. In adults, this inverse relationship exists regardless of energy intake/day, whether physical activity goals are met, sex, age and other potentially confounding sociodemographic and environmental variables.
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Affiliation(s)
- Oscar Fernando Herrán
- Escuela de Nutrición y Dietética, Universidad Industrial de Santander, Bucaramanga, Santander, Colombia
| | - Catalina Herrán-Fonseca
- Programa Medicina, Facultad de Ciencias de la Salud, Universidad Autónoma de Bucaramanga, Bucaramanga, Santander, Colombia
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Grangeiro ÉD, Trigueiro MS, Siais LDO, Paiva HM, Sola-Penna M, Alves MR, Rosado EL. Hypocaloric diet with lower meal frequency did not affect weight loss, body composition and insulin responsiveness, but improved lipid profile: a randomized clinical trial. Food Funct 2021; 12:12594-12605. [PMID: 34816273 DOI: 10.1039/d1fo00484k] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Dietary approaches are essential to control obesity, but the effectiveness of changes in meal frequency (MF) as a strategy for body weight loss or maintenance remain unclear. This study aimed to evaluate the influence of MF of a hypocaloric diet on weight loss, body composition, active ghrelin levels and metabolic indicators of obese women. This is a randomized, parallel clinical trial, including 40 women divided into two groups that received a hypocaloric diet with different MFs: MF6: six meals per day, and MF3: three meals per day. Dietary, laboratory, anthropometric and body composition indicators were assessed, as well as energy expenditure (EE), before and after the 90 days of the intervention. Dietary consumption did not differ between groups, before or after intervention. The two groups reduced their energy intake after intervention, but there were no differences between the groups. Waist circumference (WC) was reduced and resting metabolic rate had increased in the MF3 group at the end compared to baseline. Moreover, there was a significant difference in the triglyceride levels between groups after intervention, with an important reduction in the MF3 group, although changes in body composition, blood glucose, plasma ghrelin levels and EE variables did not differ between the groups at the end. It is concluded that, the hypocaloric diet with different MF each day did not change weight loss, body composition or insulin responsiveness, but there was an improvement of triglyceridemia in the MF3 group. The present study suggests that eating snacks between meals is not an important factor for weight loss and improvement of metabolic health in women with obesity.
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Affiliation(s)
- Érika Duarte Grangeiro
- Department of Nutrition and Dietetics, Nutrition Institute Josué de Castro, Federal University of Rio de Janeiro, Brazil.
| | - Mariana Silva Trigueiro
- Department of Nutrition and Dietetics, Nutrition Institute Josué de Castro, Federal University of Rio de Janeiro, Brazil.
| | - Leysimar de Oliveira Siais
- Department of Nutrition and Dietetics, Nutrition Institute Josué de Castro, Federal University of Rio de Janeiro, Brazil.
| | - Hilana Moreira Paiva
- Department of Nutrition and Dietetics, Nutrition Institute Josué de Castro, Federal University of Rio de Janeiro, Brazil.
| | - Mauro Sola-Penna
- Laboratório de Enzimologia e Controle do Metabolismo (LabECoM), Departamento de Biotecnologia Farmacêutica, Faculdade de Farmácia, Rio de Janeiro, Brazil
| | - Marcelo Ribeiro Alves
- HIV/AIDS Clinical Research Center, Evandro Chagas National Institute of Infectology, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Eliane Lopes Rosado
- Department of Nutrition and Dietetics, Nutrition Institute Josué de Castro, Federal University of Rio de Janeiro, Brazil.
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Zhang H, Jia M, Su Y, Zhu W. Feeding frequency affects glucose and lipid metabolism through SIRT1/AMPK pathway in growing pigs with the same amount of daily feed. J Nutr Biochem 2021; 100:108919. [PMID: 34843934 DOI: 10.1016/j.jnutbio.2021.108919] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 09/26/2021] [Accepted: 11/18/2021] [Indexed: 12/12/2022]
Abstract
Eating patterns are associated with obesity and metabolic health. However, the regulating mechanism of different eating patterns on body metabolism are not fully cleare. In this study, a pig model was used to evaluate the effects of feeding frequency on glucose and lipid metabolism and reveal its regulating mechanism. Twenty-four growing barrows were randomly allocated to 1-meal (M1), 3-meal (M3), or 5-meal (M5) per day groups with the same amount of daily feed. GSEA was conducted on the liver to investigate the pathways of different feeding frequencies on the metabolism. The serum glucose, NEFA, VLDL-C levels were higher for M1 group than for M3 and M5 groups, however, the hepatic TRIG level was lower. Liver transcriptome showed that glycolysis/gluconeogenesis and fatty acid metabolism pathways were suppressed with the increase of feeding frequency. The increase of gluconeogenic substrates (glycerol and lactate) and enzymes (PEPCK1 and G6Pase) in liver indicated that hepatic gluconeogenesis was enhanced in the M1 group. AMPK/PPARα signaling associated genes were positively correlated with NEFA and β-HB levels in M1 group, which promoted fatty acid oxidation and ketogenesis in liver. Moreover, compared with M3 and M5 groups, the higher NAD+/NADH ratio in the liver of M1 group activated SIRT1, which stimulated the AMPK signaling associated pathways by up-regulating the LKB1 gene. These findings provide evidence for the regulating roles of feeding frequency on glucose and lipid metabolism through SIRT1/AMPK pathway, which greatly contributes to the regulation of energy metabolism through daily eating patterns in animals.
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Affiliation(s)
- He Zhang
- Laboratory of Gastrointestinal Microbiology, Jiangsu Key Laboratory of Gastrointestinal Nutrition and Animal Health, College of Animal Science and Technology, Nanjing Agricultural University, Nanjing, Jiangsu, China; National Center for International Research on Animal Gut Nutrition, Nanjing Agricultural University, Nanjing, Jiangsu, China
| | - Menglan Jia
- Laboratory of Gastrointestinal Microbiology, Jiangsu Key Laboratory of Gastrointestinal Nutrition and Animal Health, College of Animal Science and Technology, Nanjing Agricultural University, Nanjing, Jiangsu, China; National Center for International Research on Animal Gut Nutrition, Nanjing Agricultural University, Nanjing, Jiangsu, China
| | - Yong Su
- Laboratory of Gastrointestinal Microbiology, Jiangsu Key Laboratory of Gastrointestinal Nutrition and Animal Health, College of Animal Science and Technology, Nanjing Agricultural University, Nanjing, Jiangsu, China; National Center for International Research on Animal Gut Nutrition, Nanjing Agricultural University, Nanjing, Jiangsu, China.
| | - Weiyun Zhu
- Laboratory of Gastrointestinal Microbiology, Jiangsu Key Laboratory of Gastrointestinal Nutrition and Animal Health, College of Animal Science and Technology, Nanjing Agricultural University, Nanjing, Jiangsu, China; National Center for International Research on Animal Gut Nutrition, Nanjing Agricultural University, Nanjing, Jiangsu, China
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Garcidueñas-Fimbres TE, Paz-Graniel I, Nishi SK, Salas-Salvadó J, Babio N. Eating Speed, Eating Frequency, and Their Relationships with Diet Quality, Adiposity, and Metabolic Syndrome, or Its Components. Nutrients 2021; 13:1687. [PMID: 34063439 PMCID: PMC8156274 DOI: 10.3390/nu13051687] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/11/2021] [Accepted: 05/13/2021] [Indexed: 02/06/2023] Open
Abstract
Excess body weight is a major global health concern, particularly due to its associated increased health risks. Several strategies have been proposed to prevent overweight and obesity onset. In the past decade, it has been suggested that eating speed/rate and eating frequency might be related to obesity. The main aim of this narrative review was to summarize existing evidence regarding the impact of eating speed/rate and eating frequency on adiposity, metabolic syndrome (MetS), or diet quality (DQ). For this purpose, a literature search of observational and interventional trials was conducted between June and September 2020 in PubMed and Web of Sciences databases, without any data filters and no limitations for publication date. Results suggest that children and adults with a faster eating speed/rate may be associated with a higher risk of developing adiposity, MetS or its components. Furthermore, a higher eating frequency could be associated with diet quality improvement, lower adiposity, and lower risk of developing MetS or its components. Further interventional trials are warranted to clarify the mechanism by which these eating behaviors might have a potential impact on health.
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Affiliation(s)
- Tany E. Garcidueñas-Fimbres
- Universitat Rovira i Virgili, Departament de Bioquimica i Biotecnologia, Unitat de Nutrició Humana, 43201 Reus, Spain; (T.E.G.-F.); (I.P.-G.); (S.K.N.)
- Institut d’Investigació Sanitària Pere Virgili (IISPV), 43204 Reus, Spain
- CIBER Physiology of Obesity and Nutrition (CIBEROBN), Carlos III Health Institute, 28029 Madrid, Spain
| | - Indira Paz-Graniel
- Universitat Rovira i Virgili, Departament de Bioquimica i Biotecnologia, Unitat de Nutrició Humana, 43201 Reus, Spain; (T.E.G.-F.); (I.P.-G.); (S.K.N.)
- Institut d’Investigació Sanitària Pere Virgili (IISPV), 43204 Reus, Spain
- CIBER Physiology of Obesity and Nutrition (CIBEROBN), Carlos III Health Institute, 28029 Madrid, Spain
| | - Stephanie K. Nishi
- Universitat Rovira i Virgili, Departament de Bioquimica i Biotecnologia, Unitat de Nutrició Humana, 43201 Reus, Spain; (T.E.G.-F.); (I.P.-G.); (S.K.N.)
- Institut d’Investigació Sanitària Pere Virgili (IISPV), 43204 Reus, Spain
- CIBER Physiology of Obesity and Nutrition (CIBEROBN), Carlos III Health Institute, 28029 Madrid, Spain
| | - Jordi Salas-Salvadó
- Universitat Rovira i Virgili, Departament de Bioquimica i Biotecnologia, Unitat de Nutrició Humana, 43201 Reus, Spain; (T.E.G.-F.); (I.P.-G.); (S.K.N.)
| | - Nancy Babio
- Universitat Rovira i Virgili, Departament de Bioquimica i Biotecnologia, Unitat de Nutrició Humana, 43201 Reus, Spain; (T.E.G.-F.); (I.P.-G.); (S.K.N.)
- Institut d’Investigació Sanitària Pere Virgili (IISPV), 43204 Reus, Spain
- CIBER Physiology of Obesity and Nutrition (CIBEROBN), Carlos III Health Institute, 28029 Madrid, Spain
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Abdollahi S, Kazemi A, de Souza RJ, Clark CCT, Soltani S. The effect of meal frequency on biochemical cardiometabolic factors: A systematic review and meta-analysis of randomized controlled trials. Clin Nutr 2021; 40:3170-3181. [PMID: 33485709 DOI: 10.1016/j.clnu.2020.12.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 12/16/2020] [Accepted: 12/25/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Although several randomized controlled trials (RCTs) have supported the beneficial effects of higher meal frequency (MF) on cardiometabolic risk factors, the putative effects of higher MF on health remain inconclusive. This study systematically reviewed the evidence from RCTs of the effect of higher compared with lower MF on the blood lipid profile, glucose homeostasis, and adipokines. METHODS PubMed, Scopus, ISI Web of Science, and the Cochrane database were searched up to October 2020 to retrieve relevant RCTs. A DerSimonian and Laird random effects model was used to pool mean differences and 95% CI for each outcome. The quality of studies and evidence was assessed through standard methods. RESULTS Twenty-one RCTs (686 participants) were included in this meta-analysis. Overall results showed a significant improvement in total cholesterol [weighted mean difference (WMD) = -6.08 mg/dl; 95% CI: -10.68, -1.48; P = 0.01; I2 = 88%], and low-density cholesterol (LDL-C) (WMD = -6.82 mg/dl; 95% CI: -10.97, -1.60; P = 0.009; I2 = 85.7%), while LDL-C to high-density cholesterol ratio (LDL-C: HDL-C) increased (WMD = 0.22; 95% CI: 0.07, 0.36; P = 0.003; I2 = 0.0%) in higher MF vs. lower MF. No significant effects were found on measures of glycemic control, apolipoproteins-A1 and B, or leptin. In subgroup analyses, higher MF significantly reduced serum triglyceride (TG), and increased HDL-C, compared with lower MF in interventions > 12 weeks, and decreased serum TC and LDL-C in healthy participants. A significant reduction in LDL-C also was observed in studies where the same foods given both arms, simply divided into different feeding occasions, and in feeding studies, following higher MF compared to lower MF. CONCLUSION Our meta-analysis found that higher, compared with lower MF may improve total cholesterol, and LDL-C. The intervention does not affect measures of glycemic control, apolipoproteins-A1 and B, or leptin. However, the GRADE ratings of low credibility of the currently available evidence highlights the need for more high-quality studies in order to reach a firm conclusion.
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Affiliation(s)
- Shima Abdollahi
- Department of Nutrition and Public Health, School of Public Health, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Asma Kazemi
- Nutrition Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Russell J de Souza
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Population Health Research Centre, Hamilton Health Sciences Corporation, Hamilton, ON, Canada
| | - Cain C T Clark
- Centre for Intelligent Healthcare, Coventry University, Coventry, CV1 5FB, UK
| | - Sepideh Soltani
- Yazd Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
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Schwingshackl L, Nitschke K, Zähringer J, Bischoff K, Lohner S, Torbahn G, Schlesinger S, Schmucker C, Meerpohl JJ. Impact of Meal Frequency on Anthropometric Outcomes: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. Adv Nutr 2020; 11:1108-1122. [PMID: 32437566 PMCID: PMC7490164 DOI: 10.1093/advances/nmaa056] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/03/2020] [Accepted: 04/21/2020] [Indexed: 12/23/2022] Open
Abstract
The relation between meal frequency and measures of obesity is inconclusive. Therefore, this systematic review and network meta-analysis (NMA) set out to compare the isocaloric effects of different meal frequencies on anthropometric outcomes and energy intake (EI). A systematic literature search was conducted in 3 electronic databases (Medline, Cochrane Library, Web of Science; search date, 11 March 2019). Randomized controlled trials (RCTs) were included with ≥2 wk intervention duration comparing any 2 of the eligible isocaloric meal frequencies (i.e., 1 to ≥8 meals/d). Random-effects NMA was performed for 4 outcomes [body weight (BW), waist circumference (WC), fat mass (FM), and EI], and surface under the cumulative ranking curve (SUCRA) was estimated using a frequentist approach (P-score: value is between 0 and 1). Twenty-two RCTs with 647 participants were included. Our results suggest that 2 meals/d probably slightly reduces BW compared with 3 meals/d [mean difference (MD): -1.02 kg; 95% CI: -1.70, -0.35 kg) or 6 meals/d (MD: -1.29 kg; 95% CI: -1.74, -0.84 kg; moderate certainty of evidence). We are uncertain whether 1 or 2 meals/d reduces BW compared with ≥8 meals/d (MD1 meal/d vs. ≥8 meals/d: -2.25 kg; 95% CI: -5.13, 0.63 kg; MD2 meals/d vs. ≥8 meals/d: -1.32 kg; 95% CI: -2.19, -0.45 kg) and whether 1 meal/d probably reduces FM compared with 3 meals/d (MD: -1.84 kg; 95% CI: -3.72, 0.05 kg; very low certainty of evidence). Two meals per day compared with 6 meals/d probably reduce WC (MD: -3.77 cm; 95% CI: -4.68, -2.86 cm; moderate certainty of evidence). One meal per day was ranked as the best frequency for reducing BW (P-score: 0.81), followed by 2 meals/d (P-score: 0.74), whereas 2 meals/d performed best for WC (P-score: 0.96). EI was not affected by meal frequency. In conclusion, our findings indicate that there is little robust evidence that reducing meal frequency is beneficial.
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Affiliation(s)
- Lukas Schwingshackl
- Institute for Evidence in Medicine, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany,Address correspondence to LS (e-mail: )
| | - Kai Nitschke
- Institute for Evidence in Medicine, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jasmin Zähringer
- Institute for Evidence in Medicine, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Karin Bischoff
- Institute for Evidence in Medicine, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Szimonetta Lohner
- Cochrane Hungary, Clinical Center of the University of Pécs, Medical School, University of Pécs, Pécs, Hungary
| | - Gabriel Torbahn
- Institute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nürnberg, Germany
| | - Sabrina Schlesinger
- Institute for Biometrics and Epidemiology, German Diabetes Center (DDZ), Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Christine Schmucker
- Institute for Evidence in Medicine, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany,Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
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Energy Expenditure and Changes in Body Composition during Submarine Deployment-An Observational Study "DasBoost 2-2017". Nutrients 2020. [PMID: 31952273 DOI: 10.3390/nu12010226.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The present study was designed to objectively assess the effects of 3-months submarine deployment on behavioural and metabolic determinants of metabolic health. In 13 healthy, non-obese volunteers, we using stable isotope dilution, and plasma and urinary biochemistry to characterize metabolic health before and after a 3-month submarine deployment. Volunteers worked in 6-h shifts. After deployment, we observed reduced fat-free mass (mean ± SD, -4.1 ± 3.3 kg, p = 0.003) and increased adiposity (21.9 ± 3.2% fat mass to 24.4 ± 4.7%, p = 0.01). Changes in fat-free mass were positively associated with physical activity (+0.8 kg per 0.1 increase in PAL, p = 0.03). The average physical activity level was 1.64 ± 0.26 and total energy expenditure during deployment was 2937 ± 498 kcal/d, while energy intake was 3158 ± 786 kcal/d. Fasting glucose (p = 0.03), and triglycerides (p = 0.01) declined, whereas fasting free fatty acids increased (p = 0.04). Plasma vitamin D and B12 concentrations decreased (-14%, p = 0.04, and -44%, p = 0.001, respectively), and plasma calcium, and magnesium increased (+51%, p = 0.01, and +5%, p = 0.02). Haemoglobin was unchanged, but haematocrit decreased (-2.2 ± 2.1%, p = 0.005). In conclusion, submarine deployment impairs fat-free mass maintenance and promotes adiposity. High physical activity may prevent the decline in fat-free mass. Our study confirms the need to counteract Vitamin D and B12 deficiencies, and suggests impairments in erythrocyte metabolism.
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Rietjens G, Most J, Joris PJ, Helmhout P, Plasqui G. Energy Expenditure and Changes in Body Composition during Submarine Deployment-An Observational Study "DasBoost 2-2017". Nutrients 2020; 12:nu12010226. [PMID: 31952273 PMCID: PMC7019715 DOI: 10.3390/nu12010226] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/09/2020] [Accepted: 01/11/2020] [Indexed: 12/12/2022] Open
Abstract
The present study was designed to objectively assess the effects of 3-months submarine deployment on behavioural and metabolic determinants of metabolic health. In 13 healthy, non-obese volunteers, we using stable isotope dilution, and plasma and urinary biochemistry to characterize metabolic health before and after a 3-month submarine deployment. Volunteers worked in 6-h shifts. After deployment, we observed reduced fat-free mass (mean ± SD, −4.1 ± 3.3 kg, p = 0.003) and increased adiposity (21.9 ± 3.2% fat mass to 24.4 ± 4.7%, p = 0.01). Changes in fat-free mass were positively associated with physical activity (+0.8 kg per 0.1 increase in PAL, p = 0.03). The average physical activity level was 1.64 ± 0.26 and total energy expenditure during deployment was 2937 ± 498 kcal/d, while energy intake was 3158 ± 786 kcal/d. Fasting glucose (p = 0.03), and triglycerides (p = 0.01) declined, whereas fasting free fatty acids increased (p = 0.04). Plasma vitamin D and B12 concentrations decreased (−14%, p = 0.04, and −44%, p = 0.001, respectively), and plasma calcium, and magnesium increased (+51%, p = 0.01, and +5%, p = 0.02). Haemoglobin was unchanged, but haematocrit decreased (−2.2 ± 2.1%, p = 0.005). In conclusion, submarine deployment impairs fat-free mass maintenance and promotes adiposity. High physical activity may prevent the decline in fat-free mass. Our study confirms the need to counteract Vitamin D and B12 deficiencies, and suggests impairments in erythrocyte metabolism.
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Affiliation(s)
- Gerard Rietjens
- Training Medicine and Training Physiology, Army Command/Directory of Personnel, Royal Netherlands Army, Ministry of Defence, Herculeslaan 1, 3584 AB Utrecht, The Netherlands; (G.R.); (P.H.)
- Department of Human Physiology and Sports Medicine, Vrije Universiteit Brussel, Pleinlaan 2, U-Residence, Verd. 1, 1050 Etterbeek, Brussels, Belgium
| | - Jasper Most
- Training Medicine and Training Physiology, Army Command/Directory of Personnel, Royal Netherlands Army, Ministry of Defence, Herculeslaan 1, 3584 AB Utrecht, The Netherlands; (G.R.); (P.H.)
- Department of Nutrition and Movement Sciences, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands; (P.J.J.); (G.P.)
- Correspondence: ; Tel.: +31-43-38-81-506
| | - Peter J. Joris
- Department of Nutrition and Movement Sciences, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands; (P.J.J.); (G.P.)
| | - Pieter Helmhout
- Training Medicine and Training Physiology, Army Command/Directory of Personnel, Royal Netherlands Army, Ministry of Defence, Herculeslaan 1, 3584 AB Utrecht, The Netherlands; (G.R.); (P.H.)
| | - Guy Plasqui
- Department of Nutrition and Movement Sciences, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands; (P.J.J.); (G.P.)
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Kerksick CM, Arent S, Schoenfeld BJ, Stout JR, Campbell B, Wilborn CD, Taylor L, Kalman D, Smith-Ryan AE, Kreider RB, Willoughby D, Arciero PJ, VanDusseldorp TA, Ormsbee MJ, Wildman R, Greenwood M, Ziegenfuss TN, Aragon AA, Antonio J. International society of sports nutrition position stand: nutrient timing. J Int Soc Sports Nutr 2017; 14:33. [PMID: 28919842 PMCID: PMC5596471 DOI: 10.1186/s12970-017-0189-4] [Citation(s) in RCA: 194] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 08/14/2017] [Indexed: 12/30/2022] Open
Abstract
The International Society of Sports Nutrition (ISSN) provides an objective and critical review regarding the timing of macronutrients in reference to healthy, exercising adults and in particular highly trained individuals on exercise performance and body composition. The following points summarize the position of the ISSN:Nutrient timing incorporates the use of methodical planning and eating of whole foods, fortified foods and dietary supplements. The timing of energy intake and the ratio of certain ingested macronutrients may enhance recovery and tissue repair, augment muscle protein synthesis (MPS), and improve mood states following high-volume or intense exercise. Endogenous glycogen stores are maximized by following a high-carbohydrate diet (8–12 g of carbohydrate/kg/day [g/kg/day]); moreover, these stores are depleted most by high volume exercise. If rapid restoration of glycogen is required (< 4 h of recovery time) then the following strategies should be considered:aggressive carbohydrate refeeding (1.2 g/kg/h) with a preference towards carbohydrate sources that have a high (> 70) glycemic index the addition of caffeine (3–8 mg/kg) combining carbohydrates (0.8 g/kg/h) with protein (0.2–0.4 g/kg/h)
Extended (> 60 min) bouts of high intensity (> 70% VO2max) exercise challenge fuel supply and fluid regulation, thus carbohydrate should be consumed at a rate of ~30–60 g of carbohydrate/h in a 6–8% carbohydrate-electrolyte solution (6–12 fluid ounces) every 10–15 min throughout the entire exercise bout, particularly in those exercise bouts that span beyond 70 min. When carbohydrate delivery is inadequate, adding protein may help increase performance, ameliorate muscle damage, promote euglycemia and facilitate glycogen re-synthesis. Carbohydrate ingestion throughout resistance exercise (e.g., 3–6 sets of 8–12 repetition maximum [RM] using multiple exercises targeting all major muscle groups) has been shown to promote euglycemia and higher glycogen stores. Consuming carbohydrate solely or in combination with protein during resistance exercise increases muscle glycogen stores, ameliorates muscle damage, and facilitates greater acute and chronic training adaptations. Meeting the total daily intake of protein, preferably with evenly spaced protein feedings (approximately every 3 h during the day), should be viewed as a primary area of emphasis for exercising individuals. Ingestion of essential amino acids (EAA; approximately 10 g)either in free form or as part of a protein bolus of approximately 20–40 g has been shown to maximally stimulate muscle protein synthesis (MPS). Pre- and/or post-exercise nutritional interventions (carbohydrate + protein or protein alone) may operate as an effective strategy to support increases in strength and improvements in body composition. However, the size and timing of a pre-exercise meal may impact the extent to which post-exercise protein feeding is required. Post-exercise ingestion (immediately to 2-h post) of high-quality protein sources stimulates robust increases in MPS. In non-exercising scenarios, changing the frequency of meals has shown limited impact on weight loss and body composition, with stronger evidence to indicate meal frequency can favorably improve appetite and satiety. More research is needed to determine the influence of combining an exercise program with altered meal frequencies on weight loss and body composition with preliminary research indicating a potential benefit. Ingesting a 20–40 g protein dose (0.25–0.40 g/kg body mass/dose) of a high-quality source every three to 4 h appears to most favorably affect MPS rates when compared to other dietary patterns and is associated with improved body composition and performance outcomes. Consuming casein protein (~ 30–40 g) prior to sleep can acutely increase MPS and metabolic rate throughout the night without influencing lipolysis.
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Affiliation(s)
- Chad M Kerksick
- Exercise and Performance Nutrition Laboratory, School of Health Sciences, Lindenwood University, St. Charles, MO USA
| | - Shawn Arent
- IFNH Center for Health & Human Performance, Department of Kinesiology & Health, Rutgers University, New Brunswick, NJ USA
| | - Brad J Schoenfeld
- Health Science Department, Program of Exercise Science, CUNY Lehman College, Bronx, NY USA
| | - Jeffrey R Stout
- Institute of Exercise Physiology and Wellness, University of Central Florida, Orlando, FL USA
| | - Bill Campbell
- Performance & Physique Enhancement Laboratory, Exercise Science Program, University of South Florida, Tampa, FL USA
| | - Colin D Wilborn
- Human Performance Lab, Department of Exercise Sport Science, University of Mary Hardin-Baylor, Belton, TX USA
| | - Lem Taylor
- Human Performance Lab, Department of Exercise Sport Science, University of Mary Hardin-Baylor, Belton, TX USA
| | - Doug Kalman
- Department of Athletics, Florida International University, Miami, FL USA
| | - Abbie E Smith-Ryan
- Applied Physiology Laboratory, Department of Exercise and Sport Science, University of North Carolina-Chapel Hill, Chapel Hill, NC USA
| | - Richard B Kreider
- Exercise & Sport Nutrition Lab, Human Clinical Research Facility, Department of Health & Kinesiology, Texas A&M University, College Station, TX USA
| | - Darryn Willoughby
- Exercise and Biochemical Nutrition Laboratory, Department of Health, Human Performance, and Recreation, Baylor University, Waco, TX USA
| | - Paul J Arciero
- Human Nutrition and Metabolism Laboratory, Health and Exercise Sciences Department, Skidmore College, Saratoga Springs, NY 12866 USA
| | - Trisha A VanDusseldorp
- Department of Exercise Science and Sport Management, Kennesaw State University, Kennesaw, GA USA
| | - Michael J Ormsbee
- Department of Nutrition, Food and Exercise Sciences, Institute of Sport Sciences and Medicine, Florida State University, Tallahassee, FL USA.,University of KwaZulu-Natal, Biokinetics, Exercise and Leisure Studies, Durban, 4000 South Africa
| | | | - Mike Greenwood
- Exercise & Sport Nutrition Lab, Human Clinical Research Facility, Department of Health & Kinesiology, Texas A&M University, College Station, TX USA
| | | | - Alan A Aragon
- Department of Family Environmental Sciences, California State University, Northridge, CA USA
| | - Jose Antonio
- Department of Health and Human Performance, Nova Southeastern University, Davie, FL USA
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Falivene MA, Orden AB. Maternal behavioral factors influencing postpartum weight retention. Clinical and metabolic implications. REVISTA BRASILEIRA DE SAÚDE MATERNO INFANTIL 2017. [DOI: 10.1590/1806-93042017000200003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Abstract Objectives: to describe some factors of maternal behavior such as breastfeeding, diet, physical activity, sleep and clinical-metabolic disorders associated with retention and/or weight gain during postpartum. Methods: specific articles on the subject were searched in LILACS, MEDLINE/PubMed and SciELO databases. Results: the literature review suggests that breastfeeding or physical activity alone are not enough to return to the pre-pregnancy weight, if they are not combined with restrictions of energy intake. Reduced sleep affects both eating habits and activity patterns resulting in lower energy expenditure, in addition to altering the glycemic metabolism. Conclusions: maternal obesity increases the risk of metabolic syndrome. Interventions during postpartum are critical for maternal health and could be the key in reducing the risk of transgenerational maternal/childhood obesity.
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Affiliation(s)
| | - Alicia B. Orden
- Consejo Nacional de Investigaciones Científicas y Técnicas, Argentina
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Cadegiani FA, Diniz GC, Alves G. Aggressive clinical approach to obesity improves metabolic and clinical outcomes and can prevent bariatric surgery: a single center experience. BMC OBESITY 2017; 4:9. [PMID: 28239482 PMCID: PMC5320647 DOI: 10.1186/s40608-017-0147-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 02/03/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND The number of bariatric procedures has exponentially increased in the past decade, as a result of the lack of successful clinical weight-loss interventions. The main reasons for the failure of clinical obesity management are: (1) anti-obesity medications are administered as monotherapies (or pre-combined drugs); (2) lack of combination between pharmacotherapy and non-pharmacological modalities; (3) short duration of pharmacotherapy for obesity; (4) lack of weight-loss maintenance strategies; (5) misunderstanding of the complex pathophysiology of obesity; and (6) underprescription of anti-obesity medications. We developed a protocol that can potentially overcome the drawbacks that may lead to the failure of clinical therapy for obesity. The aim of this study is therefore to report the clinical and metabolic effects of our proposed obesity-management protocol over a 2-year period, and to determine whether this more intensive approach to obesity management is feasible and a possible alternative to bariatric surgery in patients with moderate-to-severe obesity. METHODS This retrospective study involved 43 patients in whom bariatric surgery was indicated. Patients underwent an intensive anti-obesity protocol that included pharmacotherapy with multiple drugs; intense surveillance with monthly body analysis by air-displacement plethysmography, electrical bioimpedance, and 3D body scans; weekly psychotherapy; diet planning with a dietician every 2 months; and exercises at least 3 times a week with exercises prescribed by a personal trainer at least once a month. Body weight (BW), total weight excess (TWE), obesity class, body mass index, fat weight, muscle weight, waist circumference, and visceral fat were analyzed. Markers of lipid and glucose metabolism, liver function, and inflammation were also evaluated. Therapeutic success was defined as >20% BW loss or >50% decrease in TWE after 1 year. RESULTS Significant improvements were observed in all clinical and metabolic parameters. Thirty-eight (88.4%) patients achieved 10% BW loss, and 32 (74.4%) achieved 20% BW loss. TWE decreased by >50% in 35 (81.4%) patients. Forty (93.0%) patients were able to avoid bariatric surgery. CONCLUSION An intensive clinical approach to obesity management can be an effective alternative to bariatric surgery, although further randomized controlled studies are necessary to validate our findings.
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Affiliation(s)
- Flavio A Cadegiani
- Division of Endocrinology and Metabolism, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, R. Pedro de Toledo 781, 04039-032 São Paulo, SP Brazil.,Corpometria Institute, an Obesity and Endocrinology Center, SGAS 915 Centro Clínico Advance Salas 260/262/264, 70390-150 Brasilia, DF Brazil
| | - Gustavo C Diniz
- Corpometria Institute, an Obesity and Endocrinology Center, SGAS 915 Centro Clínico Advance Salas 260/262/264, 70390-150 Brasilia, DF Brazil
| | - Gabriella Alves
- Corpometria Institute, an Obesity and Endocrinology Center, SGAS 915 Centro Clínico Advance Salas 260/262/264, 70390-150 Brasilia, DF Brazil
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Abstract
PURPOSE OF REVIEW The purpose of this article is to provide an overview of the most recent human intervention trials that have examined the impact of meal frequency or meal timing on metabolic disease risk factors. RECENT FINDINGS Findings from intervention studies published over the past 12 months indicate that weight loss may be more pronounced with decreased meal frequency (two meals per day) versus increased meal frequency (six meals per day) under hypocaloric conditions. However, under isocaloric conditions, no effect on body weight was noted. Plasma lipid concentrations and glucoregulatory factors (fasting glucose, insulin, and insulin sensitivity) were not affected by alterations in meal frequency. As for meal timing, delaying the lunchtime meal by 3.5 h (from 1.30 p.m. to 4.30 p.m.) has no impact on body weight, but may impair glucose tolerance in young healthy adults. SUMMARY In sum, altering meal frequency has little impact on body weight, plasma lipids, or glucoregulatory factors, whereas eating the majority of calories later in the day may be detrimental for glycemic control. These preliminary findings, however, still require confirmation by longer term, larger scale controlled trials.
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Affiliation(s)
- Krista A Varady
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, Illinois, USA
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16
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Dashti HS, Mogensen KM. Recommending Small, Frequent Meals in the Clinical Care of Adults: A Review of the Evidence and Important Considerations. Nutr Clin Pract 2016; 32:365-377. [DOI: 10.1177/0884533616662995] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Hassan S. Dashti
- Department of Nutrition, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Kris M. Mogensen
- Department of Nutrition, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Soreca I, Wallace ML, Hall MH, Hasler BP, Frank E, Kupfer DJ. The association between meal timing and frequency with cardiometabolic profile in patients with bipolar disorder. Acta Psychiatr Scand 2016; 133:453-8. [PMID: 27084394 DOI: 10.1111/acps.12578] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/07/2016] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The goal of this study was to explore the association of timing of and frequency of meals with markers of cardiometabolic risk in patients with bipolar disorder in out-patient maintenance treatment. METHODS We used Pittsburgh Sleep Diary and actigraphy measures for individuals with bipolar I disorder. Linear and logistic regression analyses were used to determine whether dinnertime, instability of dinnertime, and/or interval between meals were associated with metabolic syndrome and its components. RESULTS Later dinnertime was associated with greater waist circumference (β = 0.25, P = 0.02) after adjusting for age, sex, dinner-to-bed interval, and sleep duration. Longer breakfast-to-lunch intervals were also associated with greater waist circumferences (β =-.35, P = .002) after adjusting for age, sex, and sleep duration. Neither instability of dinnertime nor number of meals per day was associated with the metabolic syndrome or its components. CONCLUSION Weight gain is often perceived as inevitable side-effect of medications. While patients often need to be on medication to function, a more careful lifestyle assessment with attention to social rhythms and timing of activities may be critical not only for mood stability, but also to reduce cardiovascular risk.
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Affiliation(s)
- I Soreca
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - M L Wallace
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - M H Hall
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - B P Hasler
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - E Frank
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - D J Kupfer
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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