Danit R. Shahar

Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet

BACKGROUND Trials comparing the effectiveness and safety of weight-loss diets are frequently limited by short follow-up times and high dropout rates. METHODS In this 2-year trial, we randomly assigned 322 moderately obese subjects (mean age, 52 years; mean body-mass index [the weight in kilograms divided by the square of the height in meters], 31; male sex, 86%) to one of three diets: low-fat, restricted-calorie; Mediterranean, restricted-calorie; or low-carbohydrate, non-restricted-calorie. RESULTS The rate of adherence to a study diet was 95.4% at 1 year and 84.6% at 2 years. The Mediterranean-diet group consumed the largest amounts of dietary fiber and had the highest ratio of monounsaturated to saturated fat (P<0.05 for all comparisons among treatment groups). The low-carbohydrate group consumed the smallest amount of carbohydrates and the largest amounts of fat, protein, and cholesterol and had the highest percentage of participants with detectable urinary ketones (P<0.05 for all comparisons among treatment groups). The mean weight loss was 2.9 kg for the low-fat group, 4.4 kg for the Mediterranean-diet group, and 4.7 kg for the low-carbohydrate group (P<0.001 for the interaction between diet group and time); among the 272 participants who completed the intervention, the mean weight losses were 3.3 kg, 4.6 kg, and 5.5 kg, respectively. The relative reduction in the ratio of total cholesterol to high-density lipoprotein cholesterol was 20% in the low-carbohydrate group and 12% in the low-fat group (P=0.01). Among the 36 subjects with diabetes, changes in fasting plasma glucose and insulin levels were more favorable among those assigned to the Mediterranean diet than among those assigned to the low-fat diet (P<0.001 for the interaction among diabetes and Mediterranean diet and time with respect to fasting glucose levels). CONCLUSIONS Mediterranean and low-carbohydrate diets may be effective alternatives to low-fat diets. The more favorable effects on lipids (with the low-carbohydrate diet) and on glycemic control (with the Mediterranean diet) suggest that personal preferences and metabolic considerations might inform individualized tailoring of dietary interventions. (ClinicalTrials.gov number, NCT00160108.)

The Effect of Widowhood on Weight Change, Dietary Intake, and Eating Behavior in the Elderly Population

Objectives: To assess the effect of recent widowhood on weight, dietary intake, and habits. Methods:Participants included 58 recently widowed elderly subjects and 58 married subjects who were matched on age, sex, and race. Weight change from baseline and following widowhood, dietary intake, eating behavior, depression, and cognitive and physical functioning were assessed in a clinic interview. Results:Mean weight loss and the prevalence of weight loss were significantly higher among widowed participants. They ate more meals alone, more commercial meals per week, and fewer snacks and homemade meals. They also enjoyed their eating less. A significant difference between cases and controlswas evident after adjusting for all the variables. Higher cognitive functioning score, younger age, and better appetite were protective against weight loss. Discussion:Widowed people were found to be at increased risk for weight loss. This may well be due to decreased appetite and enjoyment of their meals.

Changes in dietary intake account for seasonal changes in cardiovascular disease risk factors.

Objectives: (1) to compare dietary intake in summer and winter time; (2) to measure the change in body mass index (BMI), blood pressure and serum cholesterol between winter and summer; and (3) to determine the relationships between seasonal differences in dietary intake and BMI, blood pressure and serum cholesterol measurements.Subjects and methods: Ninety-four male industrial employees were screened twice in one year, in their work place, at winter and summer time. Workers were recruited from two factories and response rate was 95%. Health-related variables, including dietary intake, blood pressure and serum cholesterol were evaluated at each season and were compared. Correlation coefficients between seasonal differences in dietary intake and in BMI, blood pressure and serum cholesterol were calculated.Results: From summer to winter the mean values of BMI increase from 26.1 kg/cm2 to 26.6 (P=0.038), systolic blood pressure from 119.6 to 121.6 (P=0.025), diastolic blood pressure from 75.2 to 77.2 mmHg (P=0.001), total cholesterol from 200.8 to 208.6 mg/dL (P=0.001), LDL cholesterol from 125.2 to 134.9 (P=0.001) and HDL cholesterol from 42.7 to 44.3 (P=0.0084). Triglycerides levels decrease from 174 to 145 in the winter (P=0.03). Mean dietary intake of fat increases from 99.1 to 106.0 (P=0.0016), saturated fat from 43.6 to 46.3 (P=0.0137), polyunsaturated fat from 25.1 to 28.3 (P=0.0002), cholesterol from 462.0 to 497.9 (P=0.0313), sodium from 5778.5 to 8208.2 (P=0.0035), zinc from 11.6 to 12.3 (P=0.0001), vitamin B1 from 1.4 to 1.5 (P=0.002), vitamin D from 4.3 to 4.9 (P=0.0323) and vitamin E from 11.2 to 12.7 (P=0.0073). Significant correlation was shown between the seasonal increase in saturated fat and the increase in BMI (r=0.37), total cholesterol (r=0.21) and LDL cholesterol (r=0.29). Seasonal change in dietary cholesterol intake was significantly and positively correlated with serum total cholesterol (r=0.24) and LDL cholesterol (r=0.24). Blood pressure was not associated with nutritional intake variables.Conclusions: Dietary intake in summer and winter is different as well as blood pressure, BMI and serum cholesterol. The seasonal increase in fat and cholesterol intake at winter time is associated with changes in BMI and serum cholesterol.Sponsorship: The study was supported by the committee for preventive Action and Research in Occupational Health, the Ministry of Labor and Social Affairs, Jerusalem, Israel.Guarantor: Dr Estela Kristal-Boneh.

Individualized Nutritional Intervention During and After Hospitalization: The Nutrition Intervention Study Clinical Trial

OBJECTIVES: To test the hypothesis that individualized nutritional treatment during and after discharge from acute hospitalization will reduce mortality and improve nutritional outcomes.

Dietary intake and eating patterns of elderly people in Israel: who is at nutritional risk?

Objective: To determine dietary intake and eating patterns of older persons in Israel and to identify factors associated with low intake.Design: A cross-sectional study.Setting: Community-dwelling participants living in the Beer-Sheva area were interviewed at home, using a 24 h food questionnaire with additional questions regarding health and eating habits. Dietary intake was compared between people aged 65–74 and 75 y and older.Subjects: A total of 377 people over the age of 65 224 aged 65–74 and 153>75, were randomly selected from the Negev population.Results: Dietary intake of energy, fat, carbohydrates, vitamins E, C and B1 were significantly lower for people aged 75 and older compared with people aged 65–74. Low energy intake was associated with lower subjective health status for men (P<0.01), poor appetite (P<0.01) and more gastrointestinal problems (P<0.05) for women and lower snack consumption (P<0.01) for both genders. In a multivariate model, low energy intake was associated with low appetite and higher use of medication for both sexes and with frequency of eating alone and not consuming snacks for men.Conclusion: Dietary intake is lower among individuals older than 75 than in 65–74 y old. Risk factors for low intake include poor appetite and health status, gastrointestinal problems, and eating alone. Snacking enhanced dietary intake and should be encouraged in this group.Sponsorship: Goldman Fund for Ben-Gurion University of the Negev.

Gender Differences in Factors Associated with Nutritional Status of Older Medical Patients

Objectives: To evaluate gender differences in nutritional risk of older people admitted to an acute-care general medical department, and identify gender-specific risk factors. Design: Cross-sectional study. Setting: Internal Medicine Department in an acute care, university-affiliated hospital in southern Israel. Subjects: 204 cognitively intact patients aged 65 and over, admitted during a 12-month period to a general medical department. Measures of outcome: Evaluation included demographic and clinical data consisting of the sum of medical conditions and of prescribed medications, evaluation of nutritional status, cognitive status, depression assessment and functional ability. Statistical analyses were conducted to evaluate the gender specific risk factors for under-nutrition. Results: 32.5% of the men and 48.1% of the women admitted to an internal medicine department were at risk for under-nutrition. Those at nutritional risk had a higher rate of depression, lower cognitive and physical ability, poorer reported health status and more diagnosed diseases. Nutritional risk for men was associated with higher depression score, longer hospitalization, and poor appetite. For women, nutritional risk was associated with lower functional status and more diagnosed diseases. In a multivariate analysis, being a female increased the risk of under-nutrition by 3.3 fold. Conclusion: Risk of under-nutrition is prevalent among older in-patients and is gender-related. Female inpatients are at markedly increased risk for under-nutrition. The mechanism of the gender discrepancy in factors related to nutritional deterioration is complex and poorly understood.

Development of a semi-quantitative Food Frequency Questionnaire (FFQ) to assess dietary intake of multiethnic populations

The Food Frequency Questionnaire (FFQ) is one of the most commonly used methods in epidemiological studies to assess long-term nutritional exposure. The purpose of this study is to develop a general FFQ for the Israeli population and present the procedures undertaken to select foods to be included in a questionnaire for a multiethnic population. Random population cluster sampling was done using voter registration lists of the Negev Jewish population, aged 35 years and over, which were divided into three groups based on where they were born, namely: Israel, Asia–Africa and Europe–America. Participants were interviewed for their dietary intake using 24 hour recalls. Foods eaten by our subjects were aggregated into conceptually similar food groups and entered in stepwise regression models to predict variation in nutrient intake. Separate models were created for each origin group. It was found that the dietary intake was significantly lower for energy and vitamin E among European–American born subjects and significantly lower for calcium intake among Asian–African born subjects. Differences between ethnic groups were seen in the list of foods, which explained the between-person variability for energy and zinc. For most nutrients, fewer items were needed to explain the between-person variation in the group of people born in Israel. The final list of foods included 126 items and explained over 90% of the between-person variability in selected nutrients for all three groups. The newly developed FFQ for the Negev population includes 126 items that are sufficient to rank the nutritional exposure of people over 35 years old from the three origin groups in Israel.

Dairy calcium intake, serum vitamin D, and successful weight loss

BACKGROUND The role of dairy calcium intake and serum vitamin D concentrations in weight loss is controversial. OBJECTIVE The objective was to assess the association of dairy calcium intake and serum vitamin D with weight loss. DESIGN We analyzed data from participants in the 2-y Dietary Intervention Randomized Controlled Trial (DIRECT) [n = 322; mean body mass index (BMI; in kg/m²): 31; mean age: 52 y]. A representative sample (n = 126) was followed for 6 mo for serum vitamin D changes. RESULTS Baseline serum 25-hydroxyvitamin D [25(OH)D] concentrations decreased significantly across the tertiles of baseline BMI (25.6 ± 8.0, 24.1 ± 8.9, and 22.9 ± 6.8 ng/mL, respectively; P for trend = 0.02). Baseline concentrations of vitamin D and dairy calcium intake were not associated with subsequent weight loss. However, in repeated-measures models adjusted for age, sex, baseline BMI, total fat intake, and diet group assignment, higher 6-mo tertile levels of dairy calcium intake (median for tertiles: 156.5, 358.0, and 582.9 mg/d, respectively) and serum 25(OH)D (14.5, 21.2, and 30.2 ng/mL, respectively) were associated with increased weight loss across the 2-y intervention (-3.3, -3.5, and -5.3 kg, respectively, for dairy calcium; P = 0.043; -3.1, -3.8, and -5.6 kg, respectively, for vitamin D; P = 0.013). In a multivariate logistic regression adjusted simultaneously for age, sex, baseline BMI, total fat intake, diet group, vitamin D concentration, and dairy calcium, an increase of 1 SD in dairy calcium intake increased the likelihood of weight loss of >4.5 kg in the preceding 6 mo [odds ratio (OR): 1.45; P = 0.046]. A similar increase was seen for serum 25(OH)D at the 6-mo point (OR: 1.7; P = 0.009). CONCLUSION Our study suggests that both higher dairy calcium intake and increased serum vitamin D are related to greater diet-induced weight loss. This trial was registered at clinicaltrials.gov as NCT00160108.

Seasonal variations in dietary intake affect the consistency of dietary assessment

Background: Nutritional epidemiology studies are usually based on one dietary assessment without taking into account the season in which the interview is taken or adjusting for the difference in reporting dietary intake in different seasons. The semiquantitative food frequency questionnaire has become the primary questionnaire method for measuring dietary intake in epidemiological studies. The aims of this report were (a) to evaluate the effect of season on dietary intake as measured by a semiquantitative food frequency questionnaire (FFQ) conducted twice: once in summer and a second time in winter; and (b) to assess the effect of the differences in dietary intake on biochemical and anthropometric seasonal related changes, such as serum cholesterol and body mass index (BMI). Population and methods: The study population consisted of 94 male industrial employees who participated in clinical biochemical and physical examinations as well as evaluation of their dietary intake twice a year. Dietary intake was assessed using the semiquantitative FFQ that included 96 items and was conducted by a personal interview. Results: We found a significant increase in the intake of selected nutrients in winter as compared to summer as well as an increased intake of animal fat-containing foods such as meat and dairy products. Significant correlation coefficients were shown between the increase in dietary intake of saturated fat and the increase in BMI, serum total and LDL cholesterol. The increase in dietary cholesterol was significantly and positively correlated with the increase in serum total and LDL cholesterol. Conclusion: Although FFQ are designed to assess average yearly food intake, we identified significant seasonal changes in dietary intake as measured by FFQ. These changes have a health impact on our population.

Depressive symptoms and risk for malnutrition among hospitalized elderly people

Objectives: To explore the association between depressive symptoms and risk for malnutrition in hospitalized elderly people.Methods: 195 hospitalized medical patients older than 65 years of age were studied in a cross-sectional design. Depression was assessed by 30-item Geriatric Depression Scale (GDS), nutritional status was evaluated by the Mini-Nutritional Assessment (MNA). Eating and digestive problems were assessed using selected items of Nutrition Risk Index (NRI), cognitive and functional status by Folstein and Barthel indices respectively; demographic data, diagnoses and medications were obtained from medical records.Results: The prevalence of depression in the studied population was 28%. MNA scores were significantly lower among depressed patients as compared with non-depressed (22.86 vs. 24.96, p < 0.001), indicating a higher risk for undernutrition among depressed persons. After controlling for age, cognitive status, functional ability, and number of illnesses, undernutrition was significantly associated with depression (OR = 2.23; 95% CI: 1.04–4.8).Conclusions: Nutritional risk is associated with depression in aged inpatients. Close case management of the elderly hospitalized patients that include assessment and treatment for both disorders may be beneficial.