What is the required energy deficit per unit weight loss?

Why animals can outrun robots

Animals are much better at running than robots. The difference in performance arises in the important dimensions of agility, range, and robustness. To understand the underlying causes for this performance gap, we compare natural and artificial technologies in the five subsystems critical for running: power, frame, actuation, sensing, and control. With few exceptions, engineering technologies meet or exceed the performance of their biological counterparts. We conclude that biology's advantage over engineering arises from better integration of subsystems, and we identify four fundamental obstacles that roboticists must overcome. Toward this goal, we highlight promising research directions that have outsized potential to help future running robots achieve animal-level performance.

Appetite and dietary intake endpoints in cancer cachexia clinical trials: Systematic Review 2 of the cachexia endpoints series

There is no consensus on the optimal endpoint(s) in cancer cachexia trials. Endpoint variation is an obstacle when comparing interventions and their clinical value. The aim of this systematic review was to summarize and evaluate endpoints used to assess appetite and dietary intake in cancer cachexia clinical trials. A search for studies published from 1 January 1990 until 2 June 2021 was conducted using MEDLINE, Embase and Cochrane Central Register of Controlled Trials. Eligible studies examined cancer cachexia treatment versus a comparator in adults with assessments of appetite and/or dietary intake as study endpoints, a sample size ≥40 and an intervention lasting ≥14 days. Reporting was in line with PRISMA guidance, and a protocol was published in PROSPERO (2022 CRD42022276710). This review is part of a series of systematic reviews examining cachexia endpoints. Of the 5975 articles identified, 116 were eligible for the wider review series and 80 specifically examined endpoints of appetite (65 studies) and/or dietary intake (21 studies). Six trials assessed both appetite and dietary intake. Appetite was the primary outcome in 15 trials and dietary intake in 7 trials. Median sample size was 101 patients (range 40-628). Forty-nine studies included multiple primary tumour sites, while 31 studies involved single primary tumour sites (15 gastrointestinal, 7 lung, 7 head and neck and 2 female reproductive organs). The most frequently reported appetite endpoints were visual analogue scale (VAS) and numerical rating scale (NRS) (40%). The appetite item from the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) C30/C15 PAL (38%) and the appetite question from North Central Cancer Treatment Group anorexia questionnaire (17%) were also frequently applied. Of the studies that assessed dietary intake, 13 (62%) used food records (prospective registrations) and 10 (48%) used retrospective methods (24-h recall or dietary history). For VAS/NRS, a mean change of 1.3 corresponded to Hedge's g of 0.5 and can be considered a moderate change. For food records, a mean change of 231 kcal/day or 11 g of protein/day corresponded to a moderate change. Choice of endpoint in cachexia trials will depend on factors pertinent to the trial to be conducted. Nevertheless, from trials assessed and available literature, NRS or EORTC QLQ C30/C15 PAL seems suitable for appetite assessments. Appetite and dietary intake endpoints are rarely used as primary outcomes in cancer cachexia. Dietary intake assessments were used mainly to monitor compliance and are not validated in cachexia populations. Given the importance to cachexia studies, dietary intake endpoints must be validated before they are used as endpoints in clinical trials.

Maximal sustainable energy intake during transatlantic ocean rowing is insufficient for total energy expenditure and skeletal muscle mass maintenance

Studies of extreme endurance have suggested that there is an alimentary limit to energy intake (EI) of ∼2.5 × resting metabolic rate (RMR). To gain further insight, this study aimed to simultaneously measure EI, total energy expenditure (TEE) body mass and muscle mass in a large cohort of males and females of varying ages during a transatlantic rowing race. Forty-nine competitors (m = 32, f = 17; age 24-67 years; time at sea 46 ± 7 days) in the 2020 and 2021 Talisker Whisky Atlantic Challenge rowed 12-18 hday-1 for ∼3000 miles. TEE was assessed in the final week of the row using 2 H2 18 O doubly labelled water, and EI was analysed from daily ration packs over this period. Thickness of relatively active (vastus lateralis, intermedius, biceps brachaii and rectus abdominus) and inactive (gastrocnemius, soleus and triceps) muscles was measured pre (<7 days) and post (<24 h) row using ultrasound. Body mass was measured and used to calculate RMR from standard equations. There were no sex differences in males and females in EI (2.5 ± 0.5 and 2.3 ± 0.4 × RMR, respectively, P = 0.3050), TEE (2.5 ± 1.0 and 2.3 ± 0.4 × RMR, respectively, P = 0.5170), or body mass loss (10.2 ± 3.1% and 10.0 ± 3.0%, respectively, P = 0.8520), and no effect of age on EI (P = 0.5450) or TEE (P = 0.9344). Muscle loss occurred exclusively in the calf (15.7% ± 11.4% P < 0.0001), whilst other muscles remained unchanged. After 46 days of prolonged ultra-endurance ocean rowing incurring 10% body mass loss, maximal sustainable EI of ∼2.5 × RMR was unable to meet total TEE suggesting that there is indeed a physiological capacity to EI.

Effects of cardiovascular exercise on eating behaviours: Accounting for effects on stress, depression-, and anger-related emotional eating in women with obesity

Obesity remains a medical issue of great concern. Behavioural methods attempting to induce weight loss have largely failed because of a minimal understanding of stress- and depression-associated psychosocial correlates. This study extended research into the effects of exercise on weight loss through psychological pathways to improve treatments. Women with obesity (N = 108), participating in an original theory-driven cognitive-behavioural treatment within community-based health promotion centres, were evaluated over 24 months. Their mean scores on anxiety, depression, and anger at baseline were significantly higher than normative data from a general sample of United States women. Three serial mediation models were specified assessing mediation of the significant exercise→dietary change relationship. These yielded two significant paths: changes in exercise→anxiety→anxiety-associated emotional eating→self-efficacy→diet, and changes in exercise→depression→depression-associated emotional eating→self-efficacy→diet; and one non-significant path: changes in exercise→anger→anger-associated emotional eating→self-efficacy→diet. In a subsequent moderated moderation model, change in eating-related self-regulation moderated the relationship between changes in anxiety and anxiety-associated emotional eating, where exercise-associated self-regulation moderated effects from eating-related self-regulation. Dietary improvement was significantly related to weight loss over 6 (β = -0.40), 12 (β = -0.42), and 24 (β = -0.33) months. Findings indicated an increased treatment focus on the completion of moderate amounts of exercise for weight loss and, following that, attention to improvements in anxiety, depression, anxiety- and depression-associated emotional eating, self-efficacy for controlled eating, and the transfer of exercise-related self-regulation to eating-related self-regulation. Given the scope of the obesity problem, extensions of this research within field settings are warranted to accelerate application opportunities.

Lifestyle-Based Obesity Care

Lifestyle intervention is an alluring concept. Changing behaviors to reduce food intake and increase energy expenditure will reduce body weight and body fat. Large randomized clinical trials in academic settings demonstrate lifestyle intervention can produce weight loss and significant health benefits. However, they also demonstrate the problems-not all participants are able to lose even 5%, and weight regain is common. Studies conducted in real-world settings achieve modest weight loss, but no reimbursement model supports it. Health care providers need to understand the benefits and limitations of lifestyle intervention delivery in the medical office setting.

Low Energy Availability and Increased Risk of Relative Energy Deficiency in Sport (RED-S) During a 3767-km Thru-Hike on the Pacific Crest Trail: A Case Study

Long-distance "thru-hiking" has extraordinary physical demands and has become increasingly popular. This report describes a man (55 y) who thru-hiked the Pacific Crest Trail in 2021 and was at risk of developing the relative energy deficiency in sport (RED-S) syndrome. Hiking distance was 3767 km over 128 d. Eighty-eight days (69%) were full days of hiking, covering 38±8 km/d (mean±SD) in 7.9±1.6 h/d. Exercise energy expenditure above rest (heart rate vs indirect calorimetry regression method) was 2834±1518 kcal/d, total energy expenditure was 5702±1323 kcal/d, and energy intake was 4141 kcal/d. Body mass decreased by 9%, and fat mass (dual-energy X-ray absorptiometry) decreased by 46%. Energy availability (energy intake minus exercise energy expenditure) was 19.3 kcal/d/kg fat-free mass, indicating low energy availability (defined as <30 kcal/d/kg). Dual-energy X-ray absorptiometry-measured spine bone mineral density (BMD) decreased by 8.6%, with little to no decrease in total hip (-1.0%) and femoral neck (-1.5%) BMD. Total cholesterol, low-density lipoprotein cholesterol, and triglycerides increased by 24, 39, and 57%, respectively. Within 8 mo after the hike, BMD and serum lipids nearly or fully returned to baseline. No changes in high-density lipoprotein cholesterol, glycemia, or blood pressure were observed. According to guidelines, these observations are consistent with a moderate risk of RED-S, and a medical evaluation and treatment plan are advisable in order to avoid clinical manifestations (eg, stress fractures, anemia, psychological disturbances). To minimize RED-S risk, it may be prudent for thru-hikers to optimize energy availability by moderating daily hiking distances and/or increasing food intake.

Effect of Small and Large Energy Surpluses on Strength, Muscle, and Skinfold Thickness in Resistance-Trained Individuals: A Parallel Groups Design

BACKGROUND

Many perform resistance training (RT) to increase muscle mass and strength. Energy surpluses are advised to support such gains; however, if too large, could cause unnecessary fat gain. We randomized 21 trained lifters performing RT 3 d/wk for eight weeks into maintenance energy (MAIN), moderate (5% [MOD]), and high (15% [HIGH]) energy surplus groups to determine if skinfold thicknesses (ST), squat and bench one-repetition maximum (1-RM), or biceps brachii, triceps brachii, or quadriceps muscle thicknesses (MT) differed by group. COVID-19 reduced our sample, leaving 17 completers. Thus, in addition to Bayesian ANCOVA comparisons, we analyzed changes in body mass (BM) with ST, 1-RM, and MT changes via regression. We reported Bayes factors (BF10) indicating odds ratios of the relative likelihood of hypotheses (e.g., BF10 = 2 indicates the hypothesis is twice as likely as another) and coefficients of determination (R2) for regressions.

RESULTS

ANCOVAs provided no evidence supporting the group model for MT or squat 1-RM. However, moderate (BF10 = 9.9) and strong evidence (BF10 = 14.5) indicated HIGH increased bench 1-RM more than MOD and MAIN, respectively. Further, there was moderate evidence (BF10 = 4.2) HIGH increased ST more than MAIN and weak evidence (BF10 = 2.4) MOD increased ST more than MAIN. Regression provided strong evidence that BM change predicts ST change (BF10 = 14.3, R2 = 0.49) and weak evidence predicting biceps brachii MT change (BF10 = 1.4, R2 = 0.24).

CONCLUSIONS

While some group-based differences were found, our larger N regression provides the most generalizable evidence. Therefore, we conclude faster rates of BM gain (and by proxy larger surpluses) primarily increase rates of fat gain rather than augmenting 1-RM or MT. However, biceps brachii, the muscle which received the greatest stimulus in this study, may have been positively impacted by greater BM gain, albeit slightly. Our findings are limited to the confines of this study, where a group of lifters with mixed training experience performed moderate volumes 3 d/wk for 8 weeks. Thus, future work is needed to evaluate the relationship between BM gains, increases in ST and RT adaptations in other contexts.

Assessing daily energy intake in adult women: validity of a food-recognition mobile application compared to doubly labelled water

Accurate dietary assessment is crucial for nutrition and health research. Traditional methods, such as food records, food frequency questionnaires, and 24-hour dietary recalls (24HR), have limitations, such as the need for trained interviewers, time-consuming procedures, and inaccuracies in estimations. Novel technologies, such as image-based dietary assessment apps, have been developed to overcome these limitations. SNAQ is a novel image-based food-recognition app which, based on computer vision, assesses food type and volume, and provides nutritional information about dietary intake. This cross-sectional observational study aimed to investigate the validity of SNAQ as a dietary assessment tool for measuring energy and macronutrient intake in adult women with normal body weight (n = 30), compared to doubly labeled water (DLW), a reference method for total daily energy expenditure (TDEE). Energy intake was also estimated using a one-day 24HR for direct comparison. Bland-Altman plots, paired difference tests, and Pearson's correlation coefficient were used to assess agreement and relationships between the methods. SNAQ showed a slightly higher agreement (bias = -329.6 kcal/day) with DLW for total daily energy intake (TDEI) compared to 24HR (bias = -543.0 kcal/day). While both SNAQ and 24HR tended to underestimate TDEI, only 24HR significantly differed from DLW in this regard (p < 0.001). There was no significant relationship between estimated TDEI and TDEE using SNAQ (R2 = 27%, p = 0.50) or 24HR (R2 = 34%, p = 0.20) and there were no significant differences in energy and macronutrient intake estimates between SNAQ and 24HR (Δ = 213.4 kcal/day). In conclusion, these results indicate that SNAQ provides a closer representation of energy intake in adult women with normal body weight than 24HR when compared to DLW, but no relationship was found between the energy estimates of DLW and of the two dietary assessment tools. Further research is needed to determine the clinical relevance and support the implementation of SNAQ in research and clinical settings. Clinical trial registration: This study is registered on ClinicalTrials.gov with the unique identifier NCT04600596 (https://clinicaltrials.gov/ct2/show/NCT04600596).

Appetite, Energy Expenditure, and the Regulation of Energy Balance

At usual weight, energy intake and expenditure are coupled and covary to maintain body weight (energy stores). A change in energy balance, especially weight loss, invokes discoordinated effects on energy intake and output that favor return to previous weight. These regulatory systems reflect physiological changes in systems regulating energy intake and expenditure rather than a lack of resolve. The biological and behavioral physiology of dynamic weight change are distinct from those of attempts at static weight maintenance of an altered body weight. This suggests that optimal therapeutic approaches to losing or gaining vs. sustaining weight changes are different for most individuals.

The Effects of Different Modalities of an Acute Energy Deficit on Sleep and Next Morning Appetitive and Compensatory Behavior in Healthy Young Adults: The EDIES Protocol

Sleep is bi-directionally linked to energy balance. This crossover study design will evaluate the acute effect of a moderate energy deficit (500 kcal) induced by diet, exercise, or mixed (-250 kcal by diet and 250 kcal by exercise) on sleep and the next morning's appetitive responses. The study sample comprises 24 healthy young adults. The experimental measurements will be conducted in a naturalistic, momentary manner and partly assessed by the participants. The participants will undergo a run-in period in order to stabilize their sleep schedules and provide them with training on the study protocol and measurements. Indirect calorimetry will be used to determine their resting metabolic rate and peak oxygen consumption (VO₂ peak). Then, they will take part in a control session (CTL), followed by three energy deficit sessions in random order: a diet-induced energy deficit session (DED), an exercise-induced energy deficit session (EED), and a mixed energy deficit session (MED). All experimental sessions will be separated by a one-week washout. The participants' sleep will be monitored by ambulatory polysomnography, and the next morning's appetitive response will be evaluated via ad libitum food intake, appetite sensations, and food reward, measured by a food liking and wanting computerized test.

Inducing consumers to use calorie information: a multinational investigation

OBJECTIVE

We identify individuals who set daily intake budgets and examine if an intervention making people estimate their calorie intake up to a certain point in the day helps those setting daily budgets to regulate their calorie intake for the remainder of the day, after high prior consumption.

DESIGN

We conducted an online experiment in five countries: Australia, China, Germany, India, and the UK (n = 3,032) using a 2 (setting calorie budget: yes vs. no, measured) x 2 (intervention: intake reminder vs. control, manipulated) between-subjects design, with the amount of prior consumption measured. Participants were contacted in the afternoon. Those in the intervention condition were asked to estimate their prior calorie intake on that day.

MAIN OUTCOME MEASURES

We measured the individual characteristics of those who set daily calorie budgets and the intended calorie intake for the remainder of the day.

RESULTS

Among people who set daily calorie budgets, the intervention reduced intended calorie intake for the remainder of the day by 176 calories if they had already consumed a high amount of calories that day.

CONCLUSION

A timely intervention to estimate one's calorie intake can lower additional intended calorie intake among those who set daily calorie budget.

Distribution of energy intake across the day and weight loss: A systematic review and meta-analysis

Consuming a greater proportion of total energy intake earlier in the day rather than in the evening is proposed to positively influence weight loss and health, potentially due to greater synchronization of human body circadian rhythms. This systematic review provides an update on existing evidence regarding earlier distributed eating patterns in weight loss interventions. Using a robust search strategy in five electronic databases, nine randomized controlled trials investigating the impact of energy intake distribution on weight loss were identified. Following critical appraisal, a random-effects meta-analyses found that, in the context of an energy-reduced diet, distributing energy intake with a focus on earlier intake resulted in significantly greater weight loss (-1.23 kg; 95% CI 2.40, -0.06, p = 0.04). Improvements in HOMA-IR, fasting glucose, and LDL cholesterol were also seen. The current study provides a timely update on the evidence linking distribution of total daily energy intake and health, showing that a focus on earlier intakes can result in greater short-term weight loss compared with later intakes. Future studies are needed to elucidate the impact that earlier intakes may have on weight management and metabolic health.

Efficacy of progressive versus severe energy restriction on body composition and strength in concurrent trained women

PURPOSE

This study evaluated the concurrent training (CT) effect in combination with either progressive energy restriction (PER) or severe energy restriction (SER) on body composition and strength-related variables in resistance-trained women.

METHODS

Fourteen women (29.5 ± 3.8 years; 23.8 ± 2.8 kg·m^-2) were randomly assigned to a PER (n = 7) or SER (n = 7) group. Participants performed an 8-week CT program. Pre- and post-intervention measures of fat mass (FM) and fat-free mass (FFM) were assessed by dual-energy X-ray absorptiometry and strength-related variables were assessed through 1-repetition maximum (in the squat and bench press) and countermovement jump.

RESULTS

Significant reductions in FM were observed in PER and SER (Δ = - 1.7 ± 0.4 kg; P =  < 0.001; ES = - 0.39 and Δ = - 1.2 ± 0.6 kg; P = 0.002; ES = - 0.20, respectively). After correcting FFM for fat-free adipose tissue (FFAT), no significant differences for this variable were found either in PER (Δ = - 0.3 ± 0.1; P = 0.071; ES = - 0.06) or in SER (Δ = - 0.2 ± 0.1; P = 0.578; ES = - 0.04). There were no significant changes in the strength-related variables. No between-group differences were found in any of the variables.

CONCLUSION

A PER has similar effects to a SER on body composition and strength in resistance-trained women performing a CT program. Given that PER is more flexible and thus may enhance dietary adherence, it might be a better alternative for FM reduction compared to SER.

The combination of isomalto-oligosaccharides (IMO)-based dietary fiber and hypocaloric high-protein diet could improve the anthropometric profile and fasting plasma glucose of healthy adults: A repeated single-arm clinical trial

Background and aims

Meals with high protein and fiber could reduce weight and improve diabetes risk factors. Isomalto-oligosaccharide (IMO), a form of dietary fiber, could induce the afferent signal that causes appetite suppression. However, the direct effect of fiber supplementation in the form of IMO combined with a high-protein diet (HPF) on those parameters is still unknown. This study aims to investigate the effect of HPF on anthropometric parameters and blood glucose regulation of healthy subjects. 
.

Methods

Thirteen healthy subjects were given a hypocaloric high protein diet (HPD) mixed with their prepared meals for two weeks. Followed by the HPF diet for another two weeks. Their anthropometric parameters, such as body composition (total body weight, body fat percentage, and fat-free mass), BMI and waist circumference, and fasting plasma glucose, were measured.

Results

Compared to pre-intervention, HPF could significantly (p ≤ 0.004) reduce the anthropometric parameters and fasting plasma glucose. Compared to HPD, HPF could significantly (p ≤ 0.005) reduce more total body weight, body fat percentage, and BMI. In addition, HPF could induce more satiety than HPD (higher VAS score).

Conclusion

HPF could improve the subject's anthropometric parameters which is obviously beneficial in preventing the risk of developing diabetes.

Dietary protein and the glycemic index handle insulin resistance within a nutritional program for avoiding weight regain after energy-restricted induced weight loss

Background and aim

The role of dietary protein and glycemic index on insulin resistance (based on TyG index) within a nutritional program for weight loss and weight maintenance was examined.

Methods

This study analyzed 744 adults with overweight/obesity within the DIOGenes project. Patients who lost at least 8% of their initial weight (0–8 weeks) after a low-calorie diet (LCD) were randomly assigned to one of five ad libitum diets designed for weight maintenance (8–34 weeks): high/low protein (HP/LP) and high/low glycemic index (HGI/LGI), plus a control. The complete nutritional program (0–34 weeks) included both LCD plus the randomized diets intervention. The TyG index was tested as marker of body mass composition and insulin resistance.

Results

In comparison with the LP/HGI diet, the HP/LGI diet induced a greater BMI loss (p < 0.05). ∆TyG was positively associated with resistance to BMI loss (β = 0.343, p = 0.042) during the weight maintenance stage. In patients who followed the HP/LGI diet, TyG (after LCD) correlated with greater BMI loss in the 8–34 weeks period (r = −0.256; p < 0.05) and during the 0–34 weeks intervention (r = −0.222, p < 0.05) periods. ΔTyG₁ value was associated with ΔBMI₂ (β = 0.932; p = 0.045) concerning the HP/LGI diet.

Conclusions

A HP/LGI diet is beneficial not only for weight maintenance after a LCD, but is also related to IR amelioration as assessed by TyG index changes. Registration Clinical Trials NCT00390637.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12986-022-00707-y.

Timing of daily calorie loading affects appetite and hunger responses without changes in energy metabolism in healthy subjects with obesity

Morning loaded calorie intake in humans has been advocated as a dietary strategy to improve weight loss. This is also supported by animal studies suggesting time of eating can prevent weight gain. However, the underlying mechanisms through which timing of eating could promote weight loss in humans are unclear. In a randomized crossover trial (NCT03305237), 30 subjects with obesity/overweight underwent two 4-week calorie-restricted but isoenergetic weight loss diets, with morning loaded or evening loaded calories (45%:35%:20% versus 20%:35%:45% calories at breakfast, lunch, and dinner, respectively). We demonstrate no differences in total daily energy expenditure or resting metabolic rate related to the timing of calorie distribution, and no difference in weight loss. Participants consuming the morning loaded diet reported significantly lower hunger. Thus, morning loaded intake (big breakfast) may assist with compliance to weight loss regime through a greater suppression of appetite.

Simulation models of sugary drink policies: A scoping review

INTRODUCTION

Simulation modeling methods are an increasingly common tool for projecting the potential health effects of policies to decrease sugar-sweetened beverage (SSB) intake. However, it remains unknown which SSB policies are understudied and how simulation modeling methods could be improved. To inform next steps, we conducted a scoping review to characterize the (1) policies considered and (2) major characteristics of SSB simulation models.

METHODS

We systematically searched 7 electronic databases in 2020, updated in 2021. Two investigators independently screened articles to identify peer-reviewed research using simulation modeling to project the impact of SSB policies on health outcomes. One investigator extracted information about policies considered and key characteristics of models from the full text of included articles. Data were analyzed in 2021-22.

RESULTS

Sixty-one articles were included. Of these, 50 simulated at least one tax policy, most often an ad valorem tax (e.g., 20% tax, n = 25) or volumetric tax (e.g., 1 cent-per-fluid-ounce tax, n = 23). Non-tax policies examined included bans on SSB purchases (n = 5), mandatory reformulation (n = 3), warning labels (n = 2), and portion size policies (n = 2). Policies were typically modeled in populations accounting for age and gender or sex attributes. Most studies focused on weight-related outcomes (n = 54), used cohort, lifetable, or microsimulation modeling methods (n = 34), conducted sensitivity or uncertainty analyses (n = 56), and included supplementary materials (n = 54). Few studies included stakeholders at any point in their process (n = 9) or provided replication code/data (n = 8).

DISCUSSION

Most simulation modeling of SSB policies has focused on tax policies and has been limited in its exploration of heterogenous impacts across population groups. Future research would benefit from refined policy and implementation scenario specifications, thorough assessments of the equity impacts of policies using established methods, and standardized reporting to improve transparency and consistency.

Issues related to the assessment of energy balance during short-term over-, under- and refeeding in normal weight men

BACKGROUND

In humans, it is unclear how different estimates of energy balance (EB) compare with each other and whether the resulting changes in body weight (bw) and body composition (BC) are predictable and reproducible.

METHODS

This is a secondary data analysis of effects of sequential 7d over- (OF), 21d under- (UF) and 14d refeeding (RF) on EB. Energy intake (EI) was controlled at +/- 50% of energy needs in a 32 normal weight men (see Am J Clin Nutr. 2015; 102:807-819). EB was calculated (i) directly from the difference between EI and energy expenditure (EE) and (ii) indirectly from changes in BC. Changes in fat mass (FM) were compared with predicted changes according to Hall et al. (Lancet 2011; 378:826-37). Finally, within-subject reproducibility of changes in bw and BC was tested in a subgroup.

RESULTS

There were interindividual and day-by-day variabilities in changes in bw and BC. During OF and RF, the two estimates of EB were similar while with UF the indirect approach underestimated the direct estimate by 10593 ± 7506 kcal/21d (p < 0.001). Considerable differences became evident between measured and predicted changes in FM. Adjusting measured for predicted values did not reduce their interindividual variance. During UF, changes in bw and BC were reproducible, while corresponding changes during OF were not.

CONCLUSION

During hypercaloric nutrition the direct estimate of EB corresponded to the indirect estimate whereas this was not true during UF. Changes in bw and BC in response to OF were not reproducible while they were during UF.

Effects of Increased Physical Activity/Exercise on Long-Term Losses in Weight and Waist Circumference: Serial Mediation from Changes in Exercise-Related to Eating-Related Self-Regulation

BACKGROUND

Behavioral obesity treatments have generally been unsuccessful at facilitating long-term weight reductions. Increased physical activity/exercise is a strong predictor of maintained weight loss. It has been proposed this is more linked to increases in exercise-related self-regulation carrying-over to eating-related self-regulation than through direct energy expenditures.

METHODS

Women with obesity participated in 10-month community-based behavioral treatments that had theory-based foci on either self-regulation skills building (n = 59) or knowledge of weight loss methods (n = 54). Physical activity/exercise, exercise-related self-regulation, and eating-related self-regulation were assessed at baseline and months 3, 6, and 12 in the prediction of weight and waist circumference changes over 24 months.

RESULTS

Significant overall improvements on all measures were found, which were significantly greater in the self-regulation-focused group than the knowledge-focused group. Mean reductions in waist circumference/weight were - 4.64 cm/ - 5.17 kg (- 5.5% of baseline weight) and - 0.66 cm/ - 1.19 kg (- 1.2% of baseline weight), respectively. Aggregated data indicated that early increase in physical activity/exercise significantly predicted 24-month reductions in both weight and waist circumference. Serial mediation analyses indicated that a sequential path from exercise-related self-regulation (baseline-month 3) → eating-related self-regulation (baseline-month 6) → eating-related self-regulation (baseline-month 12) fully mediated the physical activity/exercise-weight/waist circumference change relationships. Energy expenditures from physical activity/exercise accounted for 21% of lost weight.

CONCLUSIONS

Findings of this field research supported benefits of progressively building self-regulation skills, first for physical activity/exercise then controlled eating, through accordingly focused behavioral treatments. Opportunities for tailoring large-scale community-based interventions grounded in theory were enhanced.

A scoping review of intermittent fasting, chronobiology, and metabolism

Chronobiology plays a crucial role in modulating many physiologic systems in which there is nutritional synergism with meal timing. Given that intermittent fasting (IF) has grown as a flexible dietary method consisting of delayed or early eating windows, this scoping review addresses the effects of IF protocols on metabolism as they relate to clinical nutrition and the circadian system. Although nocturnal habits are associated with circadian misalignments and impaired cardiometabolic profile-and nutritional physiology is better orchestrated during the day-most findings are based on animal experiments or human studies with observational designs or acute meal tests. Well-controlled randomized clinical trials employing IF protocols of delayed or early eating windows have sometimes demonstrated clinical benefits, such as improved glycemic and lipid profiles, as well as weight loss. However, IF does not appear to be more effective than traditional diets at the group level, and its effects largely depend on energy restriction. Thus, efforts must be made to identify patient biological rhythms, preferences, routines, and medical conditions before individual dietary prescription in clinical practice.

Extreme duration exercise affects old and younger men differently

Aim & Methods

Extreme endurance exercise provides a valuable research model for understanding the adaptive metabolic response of older and younger individuals to intense physical activity. Here, we compare a wide range of metabolic and physiologic parameters in two cohorts of seven trained men, age 30 ± 5 years or age 65 ± 6 years, before and after the participants travelled ≈3000 km by bicycle over 15 days.

Results

Over the 15‐day exercise intervention, participants lost 2–3 kg fat mass with no significant change in body weight. V̇O₂max did not change in younger cyclists, but decreased (p = 0.06) in the older cohort. The resting plasma FFA concentration decreased markedly in both groups, and plasma glucose increased in the younger group. In the older cohort, plasma LDL‐cholesterol and plasma triglyceride decreased. In skeletal muscle, fat transporters CD36 and FABPm remained unchanged. The glucose handling proteins GLUT4 and SNAP23 increased in both groups. Mitochondrial ROS production decreased in both groups, and ADP sensitivity increased in skeletal muscle in the older but not in the younger cohort.

Conclusion

In summary, these data suggest that older but not younger individuals experience a negative adaptive response affecting cardiovascular function in response to extreme endurance exercise, while a positive response to the same exercise intervention is observed in peripheral tissues in younger and older men. The results also suggest that the adaptive thresholds differ in younger and old men, and this difference primarily affects central cardiovascular functions in older men after extreme endurance exercise.

Dietary carbohydrate restriction augments weight loss-induced improvements in glycaemic control and liver fat in individuals with type 2 diabetes: a randomised controlled trial

AIMS/HYPOTHESIS

Lifestyle modification and weight loss are cornerstones of type 2 diabetes management. However, carbohydrate restriction may have weight-independent beneficial effects on glycaemic control. This has been difficult to demonstrate because low-carbohydrate diets readily decrease body weight. We hypothesised that carbohydrate restriction enhances the beneficial metabolic effects of weight loss in type 2 diabetes.

METHODS

This open-label, parallel RCT included adults with type 2 diabetes, HbA_1c 48-97 mmol/mol (6.5-11%), BMI >25 kg/m², eGFR >30 ml min^-1 [1.73 m]^-2 and glucose-lowering therapy restricted to metformin or dipeptidyl peptidase-4 inhibitors. Participants were randomised by a third party and assigned to 6 weeks of energy restriction (all foods were provided) aiming at ~6% weight loss with either a carbohydrate-reduced high-protein diet (CRHP, percentage of total energy intake [E%]: CH30/P30/F40) or a conventional diabetes diet (CD, E%: CH50/P17/F33). Fasting blood samples, continuous glucose monitoring and magnetic resonance spectroscopy were used to assess glycaemic control, lipid metabolism and intrahepatic fat. Change in HbA_1c was the primary outcome; changes in circulating and intrahepatic triacylglycerol were secondary outcomes. Data were collected at Copenhagen University Hospital (Bispebjerg and Herlev).

RESULTS

Seventy-two adults (CD 36, CRHP 36, all white, 38 male sex) with type 2 diabetes (mean duration 8 years, mean HbA_1c 57 mmol/mol [7.4%]) and mean BMI of 33 kg/m² were enrolled, of which 67 (CD 33, CRHP 34) completed the study. Body weight decreased by 5.8 kg (5.9%) in both groups after 6 weeks. Compared with the CD diet, the CRHP diet further reduced HbA_1c (mean [95% CI] -1.9 [-3.5, -0.3] mmol/mol [-0.18 (-0.32, -0.03)%], p = 0.018) and diurnal mean glucose (mean [95% CI] -0.8 [-1.2, -0.4] mmol/l, p < 0.001), stabilised glucose excursions by reducing glucose CV (mean [95% CI] -4.1 [-5.9, -2.2]%, p < 0.001), and augmented the reductions in fasting triacylglycerol concentration (by mean [95% CI] -18 [-29, -6]%, p < 0.01) and liver fat content (by mean [95% CI] -26 [-45, 0]%, p = 0.051). However, pancreatic fat content was decreased to a lesser extent by the CRHP than the CD diet (mean [95% CI] 33 [7, 65]%, p = 0.010). Fasting glucose, insulin, HOMA2-IR and cholesterol concentrations (total, LDL and HDL) were reduced significantly and similarly by both diets.

CONCLUSIONS/INTERPRETATION

Moderate carbohydrate restriction for 6 weeks modestly improved glycaemic control, and decreased circulating and intrahepatic triacylglycerol levels beyond the effects of weight loss itself compared with a CD diet in individuals with type 2 diabetes. Concurrent differences in protein and fat intakes, and the quality of dietary macronutrients, may have contributed to these results and should be explored in future studies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03814694.

FUNDING

The study was funded by Arla Foods amba, The Danish Dairy Research Foundation, and Copenhagen University Hospital Bispebjerg Frederiksberg.

Obesity history, physical exam, laboratory, body composition, and energy expenditure: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) on History, Physical Exam, Body Composition and Energy Expenditure is intended to provide clinicians an overview of the clinical and diagnostic evaluation of patients with pre-obesity/obesity.

Methods

The scientific information for this CPS is based upon published scientific citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

This CPS outlines important components of medical, dietary, and physical activity history as well as physical exams, with a focus on specific aspects unique to managing patients with pre-obesity or obesity. Patients with pre-obesity/obesity benefit from the same preventive care and general laboratory testing as those without an increase in body fat. In addition, patients with pre-obesity/obesity may benefit from adiposity-specific diagnostic testing - both generally and individually - according to patient presentation and clinical judgment. Body composition testing, such as dual energy x-ray absorptiometry, bioelectrical impedance, and other measures, each have their own advantages and disadvantages. Some patients in clinical research, and perhaps even clinical practice, may benefit from an assessment of energy expenditure. This can be achieved by several methods including direct calorimetry, indirect calorimetry, doubly labeled water, or estimated by equations. Finally, a unifying theme regarding the etiology of pre-obesity/obesity and effectiveness of treatments of obesity centers on the role of biologic and behavior efficiencies and inefficiencies, with efficiencies more often associated with increases in fat mass and inefficiencies more often associated with decreases in fat mass.

Conclusion

The Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) on History, Physical Exam, Body Composition and Energy Expenditure is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of pre-obesity/obesity.

Plasma FGF21 concentrations and spontaneous self-selection of protein suggest that 15% protein in the diet may not be enough for male adult rats

Protein requirement has been determined at 10%-15% energy. Under dietary self-selection, rats ingest 25%-30% energy as protein and regulate FGF21 (a hormone signaling protein deficiency) to levels lower than those measured with a 15% protein (15P) diet. Our hypothesis is that if a 15P diet was indeed sufficient to ensure protein homeostasis, it is probably a too low protein level to ensure optimal energy homeostasis. Adult male Wistar rats were used in this study. The first objective was to determine the changes in food intake, body composition, and plasma FGF21, IGF-1, and PYY concentrations in rats fed 8P, 15P, 30P, 40P, or 50P diets. The second was to determine whether the FGF21 levels measured in the rats were related to spontaneous protein intake. Rats were fed a 15P diet and then allowed to choose between a protein diet and a protein-free diet. Food intake and body weight were measured throughout the experiments. Body composition was determined at different experimental stages. Plasma samples were collected to measure FGF21, IGF-1, and PYY concentrations. A 15P diet appears to result in higher growth than that observed with the 30P, 40P, and 50P diets. However, the 15P diet probably does not provide optimal progression of body composition owing to a tendency of 15P rats to fix more fat and energy in the body. The variable and higher concentrations of FGF21 in the 15P diet suggest a deficit in protein intake, but this does not appear to be a parameter reflecting the adequacy of protein intake relative to individual protein requirements.NEW & NOTEWORTHY Under dietary self-selection, rats choose to ingest 25%-30% of energy as protein, a value higher than the protein requirement (10%-15%). According to our results, this higher spontaneous intake reflects the fact that rats fed a 15% protein diet, compared with high-protein diets, tend to bind more fat and have higher concentrations of FGF21, a hormone signaling protein deficiency. A 15% protein diet appears to be sufficient for protein homeostasis but not for optimal energy homeostasis.

Intermittent fasting and continuous energy restriction result in similar changes in body composition and muscle strength when combined with a 12 week resistance training program

Purpose

The objective of this study was to compare the effects of 12 weeks of resistance training combined with either 5:2 intermittent fasting or continuous energy restriction on body composition, muscle size and quality, and upper and lower body strength.

Methods

Untrained individuals undertook 12 weeks of resistance training plus either continuous energy restriction [20% daily energy restriction (CERT)] or 5:2 intermittent fasting [~ 70% energy restriction 2 days/week, euenergetic consumption 5 days/week (IFT)], with both groups prescribed a mean of ≥ 1.4 g of protein per kilogram of body weight per day. Participants completed 2 supervised resistance and 1 unsupervised aerobic/resistance training combination session per week. Changes in lean body mass (LBM), thigh muscle size and quality, strength and dietary intake were assessed.

Results

Thirty-four participants completed the study (CERT = 17, IFT = 17). LBM was significantly increased (+ 3.7%, p < 0.001) and body weight (− 4.6%, p < 0.001) and fat (− 24.1%, p < 0.001) were significantly reduced with no significant difference between groups, though results differed by sex. Both groups showed improvements in thigh muscle size and quality, and reduced intramuscular and subcutaneous fat assessed by ultrasonography and peripheral quantitative computed tomography (pQCT), respectively. The CERT group demonstrated a significant increase in muscle surface area assessed by pQCT compared to the IFT group. Similar gains in upper and lower body strength and muscular endurance were observed between groups.

Conclusion

When combined with resistance training and moderate protein intake, continuous energy restriction and 5:2 intermittent fasting resulted in similar improvements in body composition, muscle quality, and strength. ACTRN: ACTRN12620000920998, September 2020, retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00394-022-02804-3.

Associations of age at marriage and first pregnancy with maternal nutritional status in Nepal

Background and objectives

Women’s nutritional status is important for their health and reproductive fitness. In a population where early marriage is common, we investigated how women’s nutritional status is associated with their age at marriage (marking a geographical transfer between households), and at first pregnancy.

Methodology

We used data from a cluster-randomized control trial from lowland Nepal (n = 4071). Outcomes including body mass index (BMI) were measured in early pregnancy and trial endpoint, after delivery. We fitted mixed-effects linear and logistic regression models to estimate associations of age at marriage and age at pregnancy with outcomes, and with odds of chronic energy deficiency (CED, BMI <18.5 kg/m²), at both timepoints.

Results

BMI in early pregnancy averaged 20.9 kg/m², with CED prevalence of 12.5%. In 750 women measured twice, BMI declined 1.2 (95% confidence interval 1.1, 1.3) kg/m² between early pregnancy and endpoint, when CED prevalence was 35.5%. Early pregnancy was associated in dose-response manner with poorer nutritional status. Early marriage was independently associated with poorer nutritional status among those pregnant ≤15 years, but with better nutritional status among those pregnant ≥19 years.

Conclusions and implications

The primary determinant of nutritional status was age at pregnancy, but this association also varied by marriage age. Our results suggest that natal households may marry their daughters earlier if food insecure, but that their nutritional status can improve in the marital household if pregnancy is delayed. Marriage age therefore determines which household funds adolescent weight gain, with implications for Darwinian fitness of the members of both households.

Behaviour Change Techniques in Weight Gain Prevention Interventions in Adults of Reproductive Age: Meta-Analysis and Meta-Regression

Weight gain prevention interventions are likely to be more effective with the inclusion of behaviour change techniques. However, evidence on which behaviour change techniques (BCT) are most effective for preventing weight gain and improving lifestyle (diet and physical activity) is limited, especially in reproductive-aged adults. This meta-analysis and meta-regression aimed to identify BCT associated with changes in weight, energy intake and physical activity in reproductive-aged adults. BCT were identified using the BCT Taxonomy (v1) from each intervention. Meta-regression analyses were used to identify BCT associated with change in weight, energy intake and physical activity. Thirty-four articles were included with twenty-nine articles for the meta-analysis. Forty-three of the ninety-three possible BCT listed in the taxonomy were identified in the included studies. Feedback on behaviour and Graded tasks were significantly associated with less weight gain, and Review behaviour goals was significantly associated with lower energy intake. No individual BCT were significantly associated with physical activity. Our analysis provides further evidence for which BCT are most effective in weight gain prevention interventions. The findings support that the use of key BCT within interventions can contribute to successful weight gain prevention in adults of reproductive age.

Nutrition and physical activity: An Obesity Medicine Association (OMA) Clinical Practice Statement 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) on Nutrition and Physical Activity provides clinicians an overview of nutrition and physical activity principles applicable to the care of patients with increased body fat, especially those with adverse fat mass and adiposopathic metabolic consequences.

Methods

The scientific information and clinical guidance is based upon referenced evidence and derived from the clinical perspectives of the authors.

Results

This OMA CPS on Nutrition and Physical Activity provides basic clinical information regarding carbohydrates, proteins, fats (including trans fats, saturated fats, polyunsaturated fats, and monounsaturated fats), general principles of healthful nutrition, nutritional factors associated with improved health outcomes, and food labels. Included are the clinical implications of isocaloric substitution of refined carbohydrates with saturated fats and vice-versa, as well as definitions of low-calorie, very low-calorie, carbohydrate-restricted, and fat-restricted dietary intakes. Specific dietary plans discussed include carbohydrate-restricted diets, fat-restricted diets, very low-calorie diets, the Mediterranean diet, Therapeutic Lifestyle diet, Dietary Approaches to Stop Hypertension (DASH), ketogenic (modified Atkins) diet, Ornish diet, Paleo diet, vegetarian or vegan diet (whole food/plant-based), intermittent fasting/time restricted feeding, and commercial diet programs. This clinical practice statement also examines the health benefits of physical activity and provides practical pre-exercise medical evaluation guidance as well as suggestions regarding types and recommended amounts of dynamic (aerobic) training, resistance (anaerobic) training, leisure time physical activity, and non-exercise activity thermogenesis (NEAT). Additional guidance is provided regarding muscle physiology, exercise prescription, metabolic equivalent tasks (METS), and methods to track physical activity progress.

Conclusion

This Obesity Medicine Association Clinical Practice Statement on Nutrition and Physical Activity provides clinicians an overview of nutrition and physical activity. Implementation of appropriate nutrition and physical activity in patients with pre-obesity and/or obesity may improve the health of patients, especially those with adverse fat mass and adiposopathic metabolic consequences.

The Effectiveness of Extra Virgin Olive Oil and the Traditional Brazilian Diet in Reducing the Inflammatory Profile of Individuals with Severe Obesity: A Randomized Clinical Trial

We analyzed the effectiveness of two nutritional interventions alone and together, EVOO and the DieTBra, on the inflammatory profile of severely obese individuals. This study was an RCT with 149 individuals aged from 18 to 65 years, with a body mass index ≥ 35 kg/m², randomized into three intervention groups: (1) 52 mL/day of EVOO (n = 50); (2) DieTBra (n = 49); and (3) DieTBra plus 52 mL/day of EVOO (DieTBra + EVOO, n = 50). The primary outcomes we measured were the-neutrophil-to-lymphocyte ratio (NLR) and the secondary outcomes we measured were the lymphocyte-to-monocyte ratio (LMR); leukocytes; and C reactive protein (CRP). After 12 weeks of intervention, DieTBra + EVOO significantly reduced the total leucocytes (p = 0.037) and LMR (p = 0.008). No statistically significant differences were found for the NLR in neither the intra-group and inter-group analyses, although a slight reduction was found in the DieTBra group (−0.22 ± 1.87). We observed reductions in the total leukocytes and LMR in the three groups, though without statistical difference between groups. In conclusion, nutritional intervention with DietBra + EVOO promotes a significant reduction in inflammatory biomarkers, namely leukocytes and LMR. CRP was reduced in EVOO and DieTBra groups and NLR reduced in the DieTBra group. This study was registered at ClinicalTrials.gov under NCT02463435.

Protein-carbohydrate interaction effects on energy balance, FGF21, IGF-1, and hypothalamic gene expression in rats

Amino acids are involved in energy homeostasis, just as are carbohydrates and lipids. Therefore, mechanisms controlling protein intake should operate independently and in combination with systems controlling overall energy intake to coordinate appropriate metabolic and behavioral responses. The objective of this study was to quantify the respective roles of dietary protein and carbohydrate levels on energy balance, plasma fibroblast growth factor 21 (FGF21) and insulin growth factor 1 (IGF-1) concentrations, and hypothalamic neurotransmitters (POMC, NPY, AgRP, and CART). In a simplified geometric framework, 7-wk-old male Wistar rats were fed 12 diets containing 3%-30% protein for 3 wk, in which carbohydrates accounted for 30%-75% of the carbohydrate and fat part of the diet. As a result of this study, most of the studied parameters (body composition, energy expenditure, plasma FGF21 and IGF-1 concentrations, and Pomc/Agrp ratio) responded mainly to the protein content and to a lesser extent to the carbohydrate content in the diet.NEW & NOTEWORTHY As mechanisms controlling protein intake can operate independently and in combination with those controlling energy intakes, we investigated the metabolic and behavioral effects of the protein-carbohydrate interaction. With a simplified geometric framework, we showed that body composition, energy balance, plasma FGF21 and IGF-1 concentrations, and hypothalamic Pomc/Agrp ratio were primarily responsive to protein content and, to a lesser extent, to carbohydrate content of the diet.

Reduction in Pain and Pain Intensity with Nonpharmacological Treatment in Severely Obese Patients: A Randomized Clinical Trial

The objective of this study was to analyze the effectiveness of two nonpharmacological interventions-traditional Brazilian diet (DieTBra), and extra-virgin olive oil (EVOO)-in terms of the reduction in pain and pain intensity in individuals with severe obesity. We conducted a 12-week parallel randomized clinical trial with 149 individuals (body mass index (BMI) ≥ 35 kg/m2) who were randomized into three groups: supplementation with EVOO (n = 50), DieTBra (n = 49), and EVOO + DieTBra (n = 50). Of the total, 133 individuals with a mean BMI of 46.04 kg/m2 completed the study. By the end of the follow-up, there was a reduction in severe pain in the EVOO + DieTBra group (p = 0.003). There was a significant reduction in severe pain in the EVOO + DieTBra group (-22.7%); pain in the wrist and hand (-14.1%), upper back (-26.9%), and knees (-18.4%) in the DieTBra group; and reduction in hip pain (-11.1%) with EVOO consumption. We conclude that EVOO and DieTBra, either alone or in combination, are effective interventions to reduce pain intensity and pain in different regions in individuals with severe obesity, and have great potential for clinical application.

Energy deficiency impairs resistance training gains in lean mass but not strength: A meta-analysis and meta-regression

Short-term energy deficits impair anabolic hormones and muscle protein synthesis. However, the effects of prolonged energy deficits on resistance training (RT) outcomes remain unexplored. Thus, we conducted a systematic review of PubMed and SportDiscus for randomized controlled trials performing RT in an energy deficit (RT+ED) for ≥3 weeks. We first divided the literature into studies with a parallel control group without an energy deficit (RT+CON; Analysis A) and studies without RT+CON (Analysis B). Analysis A consisted of a meta-analysis comparing gains in lean mass (LM) and strength between RT+ED and RT+CON. Studies in Analysis B were matched with separate RT+CON studies for participant and intervention characteristics, and we qualitatively compared the gains in LM and strength between RT+ED and RT+CON. Finally, Analyses A and B were pooled into a meta-regression examining the relationship between the magnitude of the energy deficit and LM. Analysis A showed LM gains were impaired in RT+ED vs RT+CON (effect size (ES) = -0.57, p = 0.02), but strength gains were comparable between conditions (ES = -0.31, p = 0.28). Analysis B supports the impairment of LM in RT+ED (ES: -0.11, p = 0.03) vs RT+CON (ES: 0.20, p < 0.001) but not strength (RT+ED ES: 0.84; RT+CON ES: 0.81). Finally, our meta-regression demonstrated that an energy deficit of ~500 kcal · day^-1 prevented gains in LM. Individuals performing RT to build LM should avoid prolonged energy deficiency, and individuals performing RT to preserve LM during weight loss should avoid energy deficits >500 kcal day^-1 .

Stored Energy Increases Body Weight and Skeletal Muscle Mass in Older, Underweight Patients after Stroke

We conducted a retrospective observational study in 170 older, underweight patients after stroke to elucidate whether stored energy was associated with gains in body weight (BW) and skeletal muscle mass (SMM). Energy intake was recorded on admission. The energy requirement was estimated as actual BW (kg) × 30 (kcal/day), and the stored energy was defined as the energy intake minus the energy requirement. Body composition was measured by bioelectrical impedance analysis. The study participants gained an average of 1.0 ± 2.6 kg of BW over a mean hospital stay of 100 ± 42 days with a mean stored energy of 96.2 ± 91.4 kcal per day. They also gained an average of 0.2 ± 1.6 kg of SMM and 0.5 ± 2.3 kg of fat mass (FM). This means about 9600 kcal were needed to gain 1 kg of BW. In addition, a 1 kg increase in body weight resulted in a 23.7% increase in SMM and a 45.8% increase in FM. Multivariate regression analyses showed that the stored energy was significantly associated with gains in BW and SMM. Aggressive nutrition therapy is important for improving nutritional status and function in patients with malnutrition and sarcopenia.

Achieving an Optimal Fat Loss Phase in Resistance-Trained Athletes: A Narrative Review

Managing the body composition of athletes is a common practice in the field of sports nutrition. The loss of body weight (BW) in resistance-trained athletes is mainly conducted for aesthetic reasons (bodybuilding) or performance (powerlifting or weightlifting). The aim of this review is to provide dietary–nutritional strategies for the loss of fat mass in resistance-trained athletes. During the weight loss phase, the goal is to reduce the fat mass by maximizing the retention of fat-free mass. In this narrative review, the scientific literature is evaluated, and dietary–nutritional and supplementation recommendations for the weight loss phase of resistance-trained athletes are provided. Caloric intake should be set based on a target BW loss of 0.5–1.0%/week to maximize fat-free mass retention. Protein intake (2.2–3.0 g/kgBW/day) should be distributed throughout the day (3–6 meals), ensuring in each meal an adequate amount of protein (0.40–0.55 g/kgBW/meal) and including a meal within 2–3 h before and after training. Carbohydrate intake should be adapted to the level of activity of the athlete in order to training performance (2–5 g/kgBW/day). Caffeine (3–6 mg/kgBW/day) and creatine monohydrate (3–5 g/day) could be incorporated into the athlete’s diet due to their ergogenic effects in relation to resistance training. The intake of micronutrients complexes should be limited to special situations in which there is a real deficiency, and the athlete cannot consume through their diet.

Effects of testosterone administration on fMRI responses to executive function, aggressive behavior, and emotion processing tasks during severe exercise- and diet-induced energy deficit

BACKGROUND

Clinical administration of testosterone is widely used due to a variety of claimed physical and cognitive benefits. Testosterone administration is associated with enhanced brain and cognitive function, as well as mood, in energy-balanced males, although such relationships are controversial. However, the effects of testosterone administration on the brains of energy-deficient males, whose testosterone concentrations are likely to be well below normal, have not been investigated.

METHODS

This study collected functional magnetic resonance imaging (fMRI) data from 50 non-obese young men before (PRE) and shortly after (POST) 28 days of severe exercise-and-diet-induced energy deficit during which testosterone (200 mg testosterone enanthate per week in sesame oil, TEST) or placebo (sesame seed oil only, PLA) were administered. Scans were also collected after a post-energy-deficit weight regain period (REC). Participants completed five fMRI tasks that assessed aspects of: 1) executive function (Attention Network Task or ANT; Multi-Source Interference Task or MSIT; AXE Continuous Processing Task or AXCPT); 2) aggressive behavior (Provoked Aggression Task or AGG); and 3) latent emotion processing (Emotional Face Processing or EMO).

RESULTS

Changes over time in task-related fMRI activation in a priori defined task-critical brain regions during performance of 2 out of 5 tasks were significantly different between TEST and PLA, with TEST showing greater levels of activation during ANT in the right anterior cingulate gyrus at POST and during MSIT in several brain regions at REC. Changes over time in objective task performance were not statistically significant; testosterone-treated volunteers had greater self-reported anger during AGG at POST.

CONCLUSIONS

Testosterone administration can alter some aspects of brain function during severe energy deficit and increase levels of anger.

Efruxifermin in non-alcoholic steatohepatitis: a randomized, double-blind, placebo-controlled, phase 2a trial

Preclinical and clinical data suggest that fibroblast growth factor 21 (FGF21) is anti-fibrotic, improves metabolic status and has potential to treat non-alcoholic steatohepatitis (NASH). We assessed the safety and efficacy of efruxifermin, a long-acting Fc-FGF21 fusion protein, for the treatment of NASH. BALANCED was a randomized, placebo-controlled study in patients with NASH conducted at 27 centers in the United States (ClinicalTrials.gov NCT03976401 ). Eighty patients, stratified by hepatic fat fraction (HFF) and fibrosis stage, were randomized using a centrally administered minimization algorithm 1:1:1:1 to receive placebo (n = 21) or efruxifermin 28 mg (n = 19), efruxifermin 50 mg (n = 20) or efruxifermin 70 mg (n = 20) via weekly subcutaneous injection for 16 weeks. The primary endpoint-absolute change from baseline in HFF measured as magnetic resonance imaging-proton density fat fraction at week 12-was met. For the full analysis set, the least squares mean absolute changes (one-sided 97.5% confidence interval) from baseline in HFF were -12.3% (-infinity (-inf), -10.3), -13.4% (-inf, -11.4) and -14.1% (-inf, -12.1) in the 28-, 50- and 70-mg groups, respectively, versus 0.3% (-inf, 1.6) in the placebo group, with statistically significant differences between efruxifermin groups and placebo (P < 0.0001 each). Overall, 70 of 79 patients who received the study drug (89%) experienced at least one treatment-emergent adverse event (TEAE), with the majority grade 1-2 (64 (81%)), five (6%) grade 3 and one grade 4. The most commonly reported drug-related TEAEs were grade 1-2 gastrointestinal (36 (46%)). Treatment with efruxifermin significantly reduced HFF in patients with F1-F3 stage NASH, with an acceptable safety profile.

High-Protein Energy-Restriction: Effects on Body Composition, Contractile Properties, Mood, and Sleep in Active Young College Students

Background: It is often advised to ensure a high-protein intake during energy-restricted diets. However, it is unclear whether a high-protein intake is able to maintain muscle mass and contractility in the absence of resistance training. Materials and Methods: After 1 week of body mass maintenance (45 kcal/kg), 28 male college students not performing resistance training were randomized to either the energy-restricted (ER, 30 kcal/kg, n = 14) or the eucaloric control group (CG, 45 kcal/kg, n = 14) for 6 weeks. Both groups had their protein intake matched at 2.8 g/kg fat-free-mass and continued their habitual training throughout the study. Body composition was assessed weekly using multifrequency bioelectrical impedance analysis. Contractile properties of the m. rectus femoris were examined with Tensiomyography and MyotonPRO at weeks 1, 3, and 5 along with sleep (PSQI) and mood (POMS). Results: The ER group revealed greater reductions in body mass (Δ -3.22 kg vs. Δ 1.90 kg, p < 0.001, partial η ² = 0.360), lean body mass (Δ -1.49 kg vs. Δ 0.68 kg, p < 0.001, partial η ² = 0.152), body cell mass (Δ -0.85 kg vs. Δ 0.59 kg, p < 0.001, partial η ² = 0.181), intracellular water (Δ -0.58 l vs. Δ 0.55 l, p < 0.001, partial η ² = 0.445) and body fat percentage (Δ -1.74% vs. Δ 1.22%, p < 0.001, partial η ² = 433) compared to the CG. Contractile properties, sleep onset, sleep duration as well as depression, fatigue and hostility did not change (p > 0.05). The PSQI score (Δ -1.43 vs. Δ -0.64, p = 0.006, partial η ² = 0.176) and vigor (Δ -2.79 vs. Δ -4.71, p = 0.040, partial η ² = 0.116) decreased significantly in the ER group and the CG, respectively. Discussion: The present data show that a high-protein intake alone was not able to prevent lean mass loss associated with a 6-week moderate energy restriction in college students. Notably, it is unknown whether protein intake at 2.8 g/kg fat-free-mass prevented larger decreases in lean body mass. Muscle contractility was not negatively altered by this form of energy restriction. Sleep quality improved in both groups. Whether these advantages are due to the high-protein intake cannot be clarified and warrants further study. Although vigor was negatively affected in both groups, other mood parameters did not change.

Low-Carbohydrate High-Fat Diet and Exercise: Effect of a 10-Week Intervention on Body Composition and CVD Risk Factors in Overweight and Obese Women-A Randomized Controlled Trial

We assessed the effect of weight-loss induced with a low-carbohydrate-high-fat diet with and without exercise, on body-composition, cardiorespiratory fitness and cardiovascular risk factors. A total of 57 overweight and obese women (age 40 ± 3.5 years, body mass index 31.1 ± 2.6 kg∙m⁻²) completed a 10-week intervention using a low-carbohydrate-high-fat diet, with or without interval exercise. An equal deficit of 700 kcal∙day⁻¹ was prescribed, restricting diet only, or moderately restricting diet and adding exercise, producing four groups; normal diet (NORM); low-carbohydrate-high-fat diet (LCHF); normal diet and exercise (NORM-EX); and low-carbohydrate-high-fat diet and exercise (LCHF-EX). Linear Mixed Models were used to assess between-group differences. The intervention resulted in an average 6.7 ± 2.5% weight-loss (p < 0.001). Post-intervention % fat was lower in NORM-EX than NORM (40.0 ± 4.2 vs. 43.5 ± 3.5%, p = 0.024). NORM-EX reached lower values in total cholesterol than NORM (3.9 ± 0.6 vs. 4.7 ± 0.7 mmol/L, p = 0.003), and LCHF-EX (3.9 ± 0.6 vs. 4.9 ± 1.1 mmol/L, p = 0.004). Post intervention triglycerides levels were lower in NORM-EX than NORM (0.87 ± 0.21 vs. 1.11 ± 0.34 mmol/L, p = 0.030). The low-carbohydrate-high-fat diet had no superior effect on body composition, V˙O_2peak or cardiovascular risk factors compared to a normal diet, with or without exercise. In conclusion, the intervention decreased fat mass, but exercise improved body composition and caused the most favorable changes in total cholesterol and triglycerides in the NORM-EX. Exercise increased cardiorespiratory fitness, regardless of diet.

Estimating my equilibrium energy intake during lockdown: very introspective study

OBJECTIVE

To estimate the daily dietary energy intake for me to maintain a constant body weight. How hard can it be?

DESIGN

Very introspective study.

SETTING

At home. In lockdown. (Except every Tuesday afternoon and Saturday morning, when I went for a run.) PARTICIPANTS: Me. n=1.

MAIN OUTCOME MEASURES

My weight, measured each day.

RESULTS

Sleeping, I shed about a kilogram each night (1.07 (SD 0.25) kg). Running 5 km, I shed about half a kilogram (0.57 (SD 0.15) kg). My daily equilibrium energy intake is about 10 000 kJ (10 286 (SD 201) kJ). Every kJ above (or below) 10 000 kJ adds (or subtracts) about 40 mg (35.4 (SD 3.2) mg).

CONCLUSIONS

Body weight data show persistent variability, even when the screws of control are tightened and tightened.

Aggressive nutrition therapy in malnutrition and sarcopenia

Aggressive nutrition therapy is essential to improve nutrition and function in patients with malnutrition and sarcopenia. Malnutrition and sarcopenia negatively affect functional recovery and activities of daily living. Nutrition improvement is associated with better functional recovery. Target energy intake in aggressive nutrition therapy is defined as total energy expenditure (TEE) plus the amount of energy accumulated. The amount of energy accumulation per 1 kg of body weight is generally 7500 kcal. If the goal is to gain 1 kg of weight over 30 d, TEE + 250 kcal is the target daily energy intake. Aggressive nutrition therapy is implemented using a rehabilitation nutrition care process, which consists of five steps: assessment and diagnostic reasoning, diagnosis, goal setting, intervention, and monitoring. Aggressive nutrition therapy sets clear goals using the Specific, Measurable, Achievable, Relevant, and Time-bound principles. The application and effect of aggressive nutrition therapy differs depending on the etiology and condition of malnutrition. Precachexia, short bowel syndrome, and older people with mild to moderate dementia are indications for aggressive nutrition therapy. Nevertheless, aggressive nutrition therapy is usually contraindicated in cases of refractory cachexia, acute disease or injury with severe inflammation, and bedridden patients with severe dementia and reduced activity. Aggressive nutrition therapy should be combined with aggressive exercise and rehabilitation. Enhanced nutritional therapy combined with rehabilitation in patients with cerebrovascular disease, hip fracture, or acute disease is recommended in the 2018 clinical practice guidelines for rehabilitation nutrition. Further evidence for aggressive nutrition therapy is however required.

The effect of a diverting ileostomy formation on nutritional status and energy intake of patients undergoing colorectal surgery

BACKGROUND AND AIMS

The effects of ileostomy construction and colonic bypass on the general nutritional status of the patients have not yet received much attention. The aim of the present study was to assess the effect of a diverting ileostomy formation, on the nutritional intake, body composition and nutritional status biochemical markers of patients with a newly formed ileostomy.

METHODS

This was an observational study. Patients scheduled for elective rectosigmoid resection at a surgical unit of a public university hospital, were considered for study inclusion. Patients in whom a diverting ileostomy was created were assigned to the ileostomy group (n = 41), and patients who underwent rectosigmoid resection without requiring a diverting ileostomy served as a control group (n = 37). Anthropometric characteristics, body composition, dietary intake and biochemical markers representative of nutritional status were assessed preoperatively and at 40 days postdischarge (NCT02036346).

RESULTS

Anthropometric and body composition characteristics (weight, BMI and body fat percentage) significantly declined from 75 to 71.6 kg, 26.9 to 25.6 kg/m² and 28.6 to 25.6% respectively (p = 0.001 for all) in the ileostomy group, between the preoperative stage and 40 days postdischarge from the hospital. Furthermore, a significant reduction in mean daily energy intake from 1871 to 1713 kcal/day (p = 0.046) was observed in the ileostomy group 40 days after discharge compared to preoperative assessment. No significant changes in the above measured parameters were observed in the non-ileostomy group.

CONCLUSION

Diverting ileostomy can have a negative effect on general nutritional status and dietary intake of patients, during the first postoperative period. Nutritional assessment might need to be included in the routine clinical management of this patient category to prevent weight loss and impaired energy intake.

Hypocaloric Low-Carbohydrate and Low-Fat Diets with Fixed Protein Lead to Similar Health Outcomes in Obese Mice

OBJECTIVE

It is controversial whether low-carbohydrate diets are better suited for weight control and metabolic health than high-carbohydrate diets. This study examined whether these diets induce different improvements in body composition and glucose tolerance in obese mice during caloric restriction (CR).

METHODS

Male C57BL/6J mice were fed an obesogenic diet ad libitum for 18 weeks and then subjected to 6-week progressive CR of up to 40%, using either a low-fat or low-carbohydrate diet with equal protein content. Mice fed a regular chow diet ad libitum served as controls. Body mass, hindlimb muscle mass, fat mass, energy expenditure, and glucose tolerance were compared between the groups.

RESULTS

Initially low-fat and low-carbohydrate groups had similar body mass, which was 30% greater compared with controls. CR induced similar weight loss in low-fat and low-carbohydrate groups. This weight loss was mainly due to fat loss in both groups. Energy expenditure of freely moving mice did not differ between the groups. Glucose tolerance improved compared with the values before CR and in controls but did not differ between the diets.

CONCLUSIONS

Dietary carbohydrate or fat content does not affect improvements in body composition and metabolic health in obese mice exposed to CR with fixed energy and protein intake.

Glucose absorption from peritoneal dialysate is associated with a gain in fat mass and a reduction in lean body mass in prevalent peritoneal dialysis patients

The majority of peritoneal dialysates use glucose to generate an osmotic gradient for the convective removal of water and Na. Although glucose can potentially be absorbed, previous studies have failed to establish whether this leads to increased fat weight gain. We measured body composition using bioimpedance in peritoneal dialysis (PD) patients, electively starting PD, attending for their first assessment of peritoneal membrane function after 2-3 months, and then after 12 months. We studied 143 patients: eighty-nine (62·2 %) males, fifty-three (37·1 %) diabetics, mean age 61·3 (SD 14·9) years, with ninety (62·1 %) patients treated by automated PD cyclers with a daytime icodextrin exchange and thirty-seven (25·9 %) by continuous ambulatory PD. Median fat mass increased by 1·8 (-0·5 to 4·1) kg, whereas fat-free mass fell -1·3 (-2·9 to 1·0) kg, and the increase in fat mass was negatively associated with the fall in soft lean mass (r -0·41, P < 0·001). Increased fat mass was associated with measured peritoneal glucose absorption (r 0·69, P < 0·001), and glucose absorption was associated with the amount of 22·7 g/l glucose dialysate (OR 2·0, 95 % CI 1·5, 2·5, P < 0·001), peritoneal urea clearance (OR 9·5, 95 % CI 2·4, 37·1, P = 0·001) and male sex (OR 4·8, 95 % CI 1·5, 14·9, P = 0·008). We report an observational study in prevalent PD patients following body composition from their first assessment of PD membrane function for approximately 12 months, and despite the majority of patients prescribed icodextrin, we have demonstrated not only an association between intra-peritoneal glucose absorption and fat weight gain but also loss of fat-free mass.

Traditional Brazilian diet and extra virgin olive oil reduce symptoms of anxiety and depression in individuals with severe obesity: Randomized clinical trial

RATIONAL & OBJECTIVE

Although the relationship between obesity, anxiety and depression is known, the clinical benefits of nutrition therapy in individuals with obesity have been scarcely studied. This study assessed the effectiveness of a traditional Brazilian diet (DieTBra) and extra virgin olive oil (EVOO) on the symptoms of anxiety and depression in severe obese participants.

METHOD

This was a parallel randomized clinical trial in adults with severe obesity (Body Mass Index - BMI ≥ 35 kg/m²), DietBra Trial. Participants were randomized into three intervention groups in a ratio of 1: 1: 1 and followed up for 12 weeks. The three intervention groups were: 1) DieTBra, 2) 52 mL/day EVOO, and 3) DieTBra +52 mL/day EVOO. The symptoms of anxiety and depression were assessed by the Hospital Anxiety and Depression Scale. The outcome variables were: anxiety, depression and simultaneous anxiety and depression in the same individual.

RESULTS

149 severe obese individuals were randomized. The mean BMI was 46.3 ± 6.5 kg/m² with a mean age of 38.9 ± 8.7 years. After randomization, individuals on medication for depression and anxiety were excluded, totaling 129 at baseline, with 44:43:42 per group. At the end of 12 weeks 113 individuals completed the study. There was a significant reduction of symptoms for the three groups: EVOO, DieTBra and DieTBra + EVOO, respectively: anxiety 38.23% (p = 0.019), 45.83% (p=<0.014), 33.33% (p < 0.013) depression 55.17% (p=<0.001), 50.00% (p=<0.007), 34.61% (p=<0.035), and anxiety/depression 57.69% (p=<0.001), 66.67% (p=<0.014), 27.78% (p=<0.013).

CONCLUSIONS

Both DieTBra and olive oil interventions were effective in reducing symptoms of anxiety and depression in severe obese adults. These interventions can be integrated with clinical protocols for treatment of symptoms of anxiety and depression in severe obese individuals.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02463435.

Effects of Extra Virgin Olive Oil (EVOO) and the Traditional Brazilian Diet on Sarcopenia in Severe Obesity: A Randomized Clinical Trial

BACKGROUND

Nutritional interventions may have positive effects on sarcopenia and body composition.

OBJECTIVE

to evaluate the effectiveness of extra virgin olive oil (EVOO) consumption and a healthy traditional Brazilian diet (DieTBra) on improving sarcopenia indicators and reducing total body fat in severe obesity.

METHODS

A randomized controlled trial registered at ClinicalTrials.gov (NCT02463435) conducted with 111 severely obese participants randomized into three treatment groups-(1) EVOO (52 mL/day), (2) DieTBra, (3) DieTBra + EVOO (52 mL/day)-for 12 weeks. Body composition was assessed by dual-energy X-ray absorptiometry and sarcopenia by walking speed and handgrip strength.

RESULTS

Significant reductions in total body fat (p = 0.041) and body weight (p = 0.003) were observed in the DieTBra group. In the DietBra + olive oil group there was also a significant reduction in body weight (0.001) compared to the olive oil-only group. ANCOVA analyses showed reductions in total body fat in the DieTBra (p = 0.016) and DieTBra + olive oil (p = 0.004) groups. Individuals in the DieTBra group had significant improvements in their walking speed (p = 0.042) and handgrip strength (p = 0.044).

CONCLUSIONS

DieTBra contributes to improvements in handgrip strength, walking speed, and total body fat in severely obese adults. The major study was registered at ClinicalTrials.gov (NCT02463435).

Can a contemporary dietary assessment tool or wearable technology accurately assess the energy intake of professional young rugby league players? A doubly labelled water validation study

Accurate quantification of energy intake is imperative in athletes; however traditional dietary assessment tools are frequently inaccurate. Therefore, this study investigated the validity of a contemporary dietary assessment tool or wearable technology to determine the total energy intake (TEI) of professional young athletes. The TEI of eight professional young male rugby league players was determined by three methods; Snap-N-Send, SenseWear Armbands (SWA) combined with metabolic power and doubly labelled water (DLW; intake-balance method; criterion) across a combined ten-day pre-season and seven-day in-season period. Changes in fasted body mass were recorded, alongside changes in body composition via isotopic dilution and a validated energy density equation. Energy intake was calculated via the intake-balance method. Snap-N-Send non-significantly over-reported pre-season and in-season energy intake by 0.21 (2.37) MJ^.day^-1 (p = 0.833) and 0.51 (1.73) MJ^.day^-1 (p = 0.464), respectively. This represented a trivial and small standardised mean bias, and very large and large typical error. SenseWear Armbands and metabolic power significantly under-reported pre-season and in-season TEI by 3.51 (2.42) MJ^.day^-1 (p = 0.017) and 2.18 (1.85) MJ^.day^-1 (p = 0.021), respectively. This represents a large and moderate standardised mean bias, and very large and very large typical error. There was a most likely larger daily error reported by SWA and metabolic power than Snap-N-Send across pre-season (3.30 (2.45) MJ^.day^-1; ES = 1.26 ± 0.68; p = 0.014) and in-season periods (1.67 (2.00) MJ^.day^-1; ES = 1.27 ± 0.70; p = 0.012). This study demonstrates the enhanced validity of Snap-N-Send for assessing athlete TEI over combined wearable technology, although caution is required when determining the individual TEIs of athletes via Snap-N-Send.

Energy Compensation Following a Supervised Exercise Intervention in Women Living With Overweight/Obesity Is Accompanied by an Early and Sustained Decrease in Non-structured Physical Activity

Background/Objectives

Body composition (BC) does not always vary as a function of exercise induced energy expenditure (exercise EE – resting EE). Energy balance variables were measured to understand energy compensation (EC) in response to an exercise intervention performed at low (LOW) or moderate (MOD) intensity.

Subjects/Methods

Twenty-one women with overweight/obesity (33 ± 5 kg/m²; 29 ± 10 yrs; 31 ± 4 ml O₂/kg/min) were randomized to a 3-month LOW or MOD (40 or 60% of VȮ_2reserve, respectively) matched to expend 1500 kcal/week (compliance = 97 ± 5%). Body energy stores (DXA), energy intake (EI) (food menu and food diaries), resting EE (indirect calorimetry), total EE (doubly-labeled water), time spent in different activities (accelerometers), appetite (visual analog scale), eating behavior traits and food reward (liking and wanting) were assessed at baseline, after weeks 1 and 2 and at the end of the 3-month exercise intervention.

Results

EC based on BC changes (fat mass and fat-free mass) was 49 ± 79% and 161 ± 88% in LOW and MOD groups, respectively (p = 0.010). EI did not change significantly during the intervention. However, eating behavior traits and food reward had changed by the end of the 3-month supervised exercise. Non-structured physical activity (NSPA) decreased across the intervention (p < 0.002), independent of the intensity of the exercise training.

Conclusion

Women with overweight/obesity training at LOW presented lower EC for a given energy cost of exercise. Our results strongly suggest that NSPA plays a major role in mediating the effects of exercise on energy balance and ultimately on changes in BC.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier ISRCTN31641049.

Calories Purchased by Hospital Employees After Implementation of a Cafeteria Traffic Light-Labeling and Choice Architecture Program

IMPORTANCE

Nearly one-third of the 150 million US adults who are employed are obese. A workplace program that reduces employees' caloric intake could help prevent obesity.

OBJECTIVE

To determine if implementation of a hospital workplace cafeteria healthy eating program was associated with reduction in calories purchased by employees over 2 years.

DESIGN, SETTING, AND PARTICIPANTS

A longitudinal cohort study of 5695 employees who purchased food with their employee identification card before and after implementation of a workplace cafeteria healthy eating program was conducted from December 1, 2009, to February 29, 2012, in a hospital in Boston, Massachusetts. Statistical analysis was conducted from April 6, 2018, to May 14, 2019.

EXPOSURE

After a 3-month baseline period, "traffic light" food labels (in which green indicates healthy, yellow indicates less healthy, and red indicates least healthy) and choice architecture (product placement) changes were implemented permanently.

MAIN OUTCOME AND MEASURES

Main outcomes were changes in calories of employees' purchases from baseline (December 1, 2009, to February 28, 2010) to the same quarter 1 year (December 1, 2010, to February 28, 2011) and 2 years (December 1, 2011, to February 29, 2012) later. Purchases were obtained from sales data linked to employee identification cards. The hypothesized association of estimated changes in daily calories consumed with employees' weight was calculated using a dynamic model of weight change. Analyses were adjusted for age, sex, race/ethnicity, and job type.

RESULTS

Among the 5695 employees in the study, 4057 were women and 1638 were men, and the mean (SD) age was 40 (12) years. Baseline purchases had a mean of 565 kcal per transaction (95% CI, 558-572 kcal) and decreased 19 kcal per transaction (95% CI, -23 to -15 kcal) at 1 year and 35 kcal per transaction (95% CI, -39 to -31 kcal) at 2 years (-6.2%; P < .001) relative to baseline. The largest reduction was from red-labeled items, decreasing 42 kcal per transaction at 2 years (95% CI, -45 to -39 kcal) from a mean of 183 kcal per transaction (95% CI, 177-188 kcal) at baseline (-23.0%; P < .001). Calories from green-labeled items increased 6 kcal per transaction (95% CI, 3-9 kcal) from a mean of 152 kcal per transaction (95% CI, 149-155 kcal) (4.0%; P < .001), and calories from yellow-labeled items did not change. Among frequent purchasers (≥36 transactions per quarter; n = 453), total kilocalories per quarter at baseline was 41 784, which, averaged over the entire follow-up, decreased a mean of 4275 kcal/quarter (95% CI, -5325 to -3224 kcal) over 2 years. Assuming no compensatory changes in diet or activity, this equated to a reduction of 47 kcal per day and estimated a 2.0-kg weight loss over 3 years.

CONCLUSIONS AND RELEVANCE

A workplace cafeteria traffic light-labeling and choice architecture program was associated with a sustained decrease in calories purchased, particularly from unhealthy foods. Point-of-purchase programs could help improve dietary intake and prevent obesity in employees.