1 Alford BB, Blankenship AC, Hagen RD: The effects of variations in carbohydrate, protein and fat content of the diet upon weight loss, blood values and nutrient intake of adult obese women. Am J Diet Assoc 1990;90:534-540.
2 Golay A, Allaz AF, Morel Y, et al: Similar weight loss with low or high-carbohydrate diet. Am J Clin Nutr 1996;63:174-178.
3 Golay A, Allaz AF, Ybarra J, et al: Similar weight loss with low-energy food combining or balancing diets. Int J Obes 2000;24:492-496.
4 Samaha FF, Iqbal N, Seshadri P, et al: A low-carbohydrate as compared with a low-fat diet in severe obesity. N Engl J Med 2003;348:2074-2081.
5 Stern L, Iqbal N, Seshadri P, et al: The effects of low-carbohydrate versus conventional weight loss diets in elderly obese adults. Ann Intern Med 2004;140:778-785.
6 Klem ML, Wing RR, McGuire MT, et al: A descriptive study of individuals successful at long-term maintenance of substantial weight loss. Am J Clin Nutr 1997;66:239-246.
7 Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults - the Evidence Report. Obes Res 1998;6(suppl 2):51S-209S.
8 Meyers AW, Graves TJ, Whelan JP, et al: An evaluation of television-delivered behavioral weight loss program: are the ratings acceptable. J Consult Clin Psychol 1996;64:172-178.
9 Pavlou KN, Krey S, Steffee W: Exercise as an adjunct to weight loss and maintenance in moderately obese subjects. Am J Clin Nutr 1989;49:1115-1123.
10 Klem ML, Wing RR, McGuire MT, et al: A descriptive study of individuals successful at long-term maintenance of substantial weight loss. Am J Clin Nutr 1997;66:239-246.
11 Golay A, Bobbioni E: The role of dietary fat in obesity. Int J Obes Relat Metab Disord 1997;21(suppl 3):S2-S11.
12 Fossati M, Amati F, Painot D, et al: Cognitive-behavioral therapy with simultaneous nutritional and physical activity education in obese patients with binge eating disorder. Eating Weight Disord 2004;9:134-138.
13 Golay A, Buclin S, Ybarra J, et al: New interdisciplinary cognitive-behavioral-nutritional approach to obesity treatment: a 5-year follow-up study. Eating Weight Disord 2004;9: 29-34.
14 Wadden TA, Berkowitz RI, Womble FG, et al: Randomized trial of lifestyle modification and pharmacotherapy for obesity. N Engl J Med 2005;353:2111-2120.
15 Golay A, Bloise D, Maldonato A: The education of people with diabetes; in Pickup J, Williams G (eds): Textbook of Diabetes, ed 2. Oxford, Blackwell, 2002, chapt. 38, pp 1-13.
16 Maldonato A, Segal P, Golay A: The diabetes education study group and its activities to improve the education of people with diabetes in Europe. Patient Educ Couns 2001 ;44: 87-97.
17 Bourbeau J, Julien M, Maltais F, et al: Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention. Arch Intern Med 2003;163:585-591.
19 Golay A, Girard A, Grandin S, et al: A new educational program for patients suffering from sleep apnea syndrome. Patient Educ Couns 2005, in press.
20 Eriksson S, Kaati G, Bygren LO: Personal resources, motives and patient education leading to changes in cardiovascular risk factors. Patient Educ Couns 1998;34:159-168.
21 WHO Regional Office for Europe: Therapeutic Patient Education, Continuing Education Programs for Healthcare Providers in the Field of Prevention of Chronic Diseases. Report of a WHO Working Group. Copenhagen, WHO, 1998.
22 Assal JP, Albeanu A, Peter-Riesch B, et al: The cost of training a diabetic patient: effects on prevention of amputation. Diab Metab 1993;19:491-495.
23 Giordan A, Golay A, Jacquemet S, et al: Communication thérapeutique. L'impact d'un message dans le processus d'apprendre. Psychothérapies 1996;16:189-193.
24 Golay A, Volery M, Rieker A, et al: Approche cognitivo-comportementale; in Basdevant A, Guy-Grand B (eds): Médecine de l'obésité. Paris, Médecine-Sciences Flammarion, 2004, pp 246-252.
25 Fossati M, Rieker A, Golay A: Thérapie cognitive en groupe de l'estime de soi chez des patients obèses, un nouvel outil: la fleur de l'estime. J Thér Comportement Cogn 2004;14:29-34.
26 Miller W, Rollnick S: Motivational Interviewing: Preparing People for Change, ed 2. New York, Guilford Press, 2002.
27 Rogers C: Counseling and Psychotherapy: Newer Concept in Practice. Boston, Houghton Miffling, 1957.
Dr. Chiasson: I would like to come back to the sympathetic nervous system response. It is very interesting because it is one of the reasons why when an extremely low diet is used it doesn't work. What is the mechanism; how is that regulated? How do you measure that, and what do you think is the problem with the autonomous nervous system?
Dr. Golay: We have two different techniques. The first one is laser Doppler measurement of the microvascular in the finger and the second one is heart rate monitoring. We have 24-hour heart rate monitoring with a spectral analysis. For the second question, the reason for this unbalance is the many questions behind it. It is known that the sympathetic nervous system is higher in obese patients. Thus, obese patients cannot further increase their system, and then they have no possibility of increasing their fat oxidation. So we have many hypotheses behind this; we are also measuring different hormones. A new one is apelin which can connect the periphery and the heart and perhaps the brain. But this is a new area and is quite interesting.
Dr. Katsilambros: I would like to make a comment on the question of Dr. Chiasson. We also had the possibility of measuring heart rate variability in obese and non-obese people under different circumstances. In the last years we have published some papers showing that after a meal the activation of the heart sympathetic nervous system is different depending on whether a person is obese or non-obese. If a person is obese the activation of the heart sympathetic nervous system is low as compared to a lean control person. In addition, if obese and lean people are given fat meals, you observe that they do not react at all, but there is a very slow and nonsignificant increase in the heart sympathetic activity. But if you give an isoenergetic carbohydrate meal to these persons then there is a clear-cut activation of the heart sympathetic activity in the lean people which, however, is not present in the obese people.
Dr. Golay: I know your studies and we are doing the same thing. Carbohydrate and proteins are very important for increasing the sympathetic nervous system, but this is not the case for fat. It is even worse with saturated fat. And as we discussed before, n-3 and n-6 are very much better for increasing the sympathetic nervous system. So the key answer is in the fat content of the diet.
Dr. T. Wilkin: Can I clarify in relation to spectral analysis? Is it a feature of obesity or is it a feature of insulin resistance that variability is lost? In other words, are there individuals who have a distribution of body fat which is not cause of insulin resistance?
Dr. Golay: It is an interesting question. I am a diabetologist and the first measurement I made was in diabetic patients. However, in insulin-resistant patients, we also found a defect. Now we are looking at children from obese patients and I cannot give the data today, but my feeling is that it is probably before insulin resistance or diabetes. Today, it is only a hypothesis.
Dr. Zhao: We know that in general vegetarian animals are less aggressive than meat-eating species. So I am just curious if there could be a relationship between the food consumed and the emotional and behavioral responses. So my question is, are there any papers available to show this association?
Dr. Golay: I totally agree with you but I don't have any data showing that hypothesis. We are smiling about this but it is probably true, especially with high sugar. Patients are probably more active and more excited if they are more sugar free. But we need a lot of research in this field. I am sure nutrition is related to emotion, perhaps to depression, etc.; when you have a lack of tryptophan you have a lack of serotonin and then depression. In some studies we have tried to improve the tryptophan intake, and to decrease other proteins. The humor and depression are improved and especially also sugar craving. So a lot of research is needed in this field. Nutrition is a completely open field of research.
Dr. Hill: I have two questions about your energy economy concept. First it was done in bariatric patients and there is a lot of speculation that with the surgery you get some changes in the gut hormones which in fact can affect metabolism. Have you found the same results in weight loss produced without bariatric surgery? And the second question is that it looks as though after a year the expected and the actual energy expenditure are the same, suggesting that the energy economy may be more important for weight loss, not so much for weight loss maintenance.
Dr. Golay: You are totally right. As to the second question, the energy economy is much smaller at the beginning, and after a weight loss program it is around 200 cal. When you lose weight you also decrease your total energy expenditure so the energy economy at that time for weight maintenance is even more crucial and important. As to your first question, of course we were looking for a normal body weight loss program and we had the same type of results. However, it is more difficult because the variation is bigger. With the bypass weight loss program, we are quite confident with our results from this type of surgical operation. We have at least the same size of stomach and almost the same size of meals, and thus the variation is smaller. One question still remains open: ghrelin suppression after this type of bypass.
Dr. T. Wilkin: One of the observations of that energy economy is the reduced conversion peripherally of thyroxin to triiodothyronine, from T4 to T3, which can be quite a striking change for a period of time. Is there any therapeutic potentially possible and advantageous intervention to prevent that occurring?
Dr. Golay: Concerning the first comment, it is probably true that the conversion between T4 and T3 is one of the reasons. The second reason is also thermogenesis pathways. What the treatment should be is difficult to say at this time, but definitely not thyroid hormones. We need different studies with leptin replacement. The leptin concentration really drops during a weight loss program in this kind of economy phase, but we were not successful. We have other possibilities, but we have to understand that weight loss during the first months is almost the same for everybody, but the difference is between 3 and 12 months for the second phase, the slow phase. And physical exercise is crucial in this phase.
Dr. Ott: I have a question regarding Singapore. As you know Singapore performs nutritional surveys at regular intervals to assess the health status of its population. As a result of this, using television, radio and so on, they recommend consuming four servings of fruits and vegetables per day and physical exercise. They also implement school programs. Do we have any evidence that this kind of activity is effective? I believe the prevalence of diabetes is low in Singapore. Do you have any data?
Dr. Golay: In fact, we are doing this kind of program in Geneva today. There are many dieticians in schools, so every teenager can receive this kind of advice, which is part of the program now in schools. We are also trying to have a program for physical exercise paid for by the government. The results are not yet known but I am quite confident that it is the right way to go because we have to start as early as possible. Just before we were talking about economy. We published two papers recently on economy in Switzerland [1, 2]. 98% of our costs for obese patients are due to complications; we paid only 1.5-2% for an obesity program, which is really nothing. We published another paper where we were looking for the effect of weight loss in diabetic patients . We pooled some data with Swedish friends and were able to prove that EUR 14,000/patient/year is saved when a diabetic patient loses 9 kg. It costs a huge amount of money to treat diabetes, myocardial infarctions and all these kind of complications.
Dr. Haschke: I am not familiar with the situation in Asia but in Germany the same recommendation has been on the table for several years; i.e. to eat 4-5 servings of vegetables and fruits per day. Two years ago there was the first big population survey on public awareness of the recommendation, how people feel about it, and how they adhere to it. The awareness was very high; 80% of the population knew of this recommendation, but only 5% adhered to it. So I cannot comment on the Asian populations but in Germany it is rather difficult to move forward. Perhaps the recommendations should be phrased in a different way.
Dr. Golay: This is exactly what we think. The information is not enough, we should do more than that. We need really to implement behavior courses. Everybody knows that it is very difficult to put into practice. It is like smoking, if you have a lot of people smoking around you, you are more prone to smoke and it is difficult to stop. So I think we need time, we need more publicity, we are fighting against big companies like McDonalds and Coca Cola.
Dr. Wuersch: Can you comment on your experience with the low glycemic index foods in your treatments?
Dr. Golay: There was a big discussion yesterday. For me, the low glycemic index is a good tool, at least for diabetic patients. However, today we are more convinced that it is also helping satiety, and by giving snacks to our obese patients suffering from binge eating disorders (allowed snacks, not nibbling), it is working very well for satiety. When a snack is given they eat less at the next meal. This is important to have a structure for your meals.
Dr. L. Wilkin: I want to talk about children for a moment. I am wondering whether it is easier or harder for children to maintain a healthy weight than adults. Perhaps there are a fewer children with so-called eating disorders, binge eating and so on, but maybe children are more susceptible to our obesogenic environment. Would you like to comment?
Dr. Golay: It depends on age. For teenagers I think it is easier because you can put a teenager in a certain position to be against the parents, to eat differently from their parents, so it is much easier. But for children, they eat in the family so we need to change the eating habits and behavior of a child with the whole family. That is why we need to go for nutrition courses in school, and to bring the parents into this kind of course. But I know it is a very difficult task.
Dr. Eshki: Weight loss programs and weight loss studies have been focusing on the efficacy of the diet alone and not on the safety of the diet. The safety parameters I am referring to are the daily recommended intakes. Don't you think this missing margin may have big effects on the results of your study and other similar studies in the long-term?
Dr. Golay: The safety of a diet for me is the amount of protein, and first you should have enough protein. You can find very strange diets without any proteins and the patients lose lean body mass. In terms of safety, restrictive diets should not be given.
Dr. Eshki: When you are talking about protein, and it is used a lot, and you want to reduce or increase it, you can't ignore the calcium intake for instance because it could cause osteoporosis in the future. So what I am trying to say is that we should not take a narrow view but try to look at the micronutrients also. That is what I mean by safety.
Dr. Golay: For the last 5 years we have been doing some studies on micronutrients. I think it is a really interesting field. In obese patients I always found a deficit for oligo elements, for vitamins, for different types of fats. And one of our suggestions today is to supplement n-3. I think in the near future we will have to be more careful with the composition of the diet, especially in diabetes.
1 Schmid A, Schneider H, Golay A, Keller U: Economic burden of obesity and its comorbidities in Switzerland. Soz Praventivmed 2005;50:87-94.
2 Ruof J, Golay A, Berne C, et al: Orlistat in responding obese type 2 diabetic patients: meta-analysis findings and cost-effectiveness as rationales for reimbursement in Sweden and Switzerland. Int J Obes (Lond) 2005;29:517-523.
3 Golay A, Ybarra J: Link between obesity and type 2 diabetes. Best Pract Res Clin Endocrinol Metab 2005;19:649-663.
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