The role of structure in dietary approaches for the treatment of pediatric overweight and obesity: A critical review.

A multicomponent approach for the treatment of pediatric overweight/obesity, which includes behavioral strategies to alter diet and physical activity/sedentary behavior, has graded recommendations for its use. Dietary interventions to be used within this approach do not. In adults, research indicates that strongly graded dietary interventions providing greater structure (or more control over the types/amount of food consumed) produce better weight outcomes. For this critical review, dietary interventions recommended by the Expert Committee for the treatment of pediatric overweight/obesity were categorized according to their potential degree of dietary structure, and their impact on weight outcomes was described. Four levels of dietary structure were reviewed, operationalized as alterations to the following: food groups, such as fruits and vegetables (low structure); daily eating occasions, such as meals (moderate structure); large nutrients, such as energy (high structure); and energy plus additional dietary alterations (very high structure). In total, 24 interventions (four low, three moderate, five high, and 12 very high structure structure) were identified and reviewed. Reductions in standardized body mass index increased with increasing structure, and interventions ≥6 months had better outcomes than interventions <6 months. Future research should empirically test dietary intervention structure to determine its impact on weight status during pediatric overweight/obesity treatment.

The Influence of Mindful Eating and/or Intuitive Eating Approaches on Dietary Intake: A Systematic Review.

BACKGROUND: Stimuli that promote eating in the absence of the physiological need for food are pervasive and can facilitate excessive energy intake. The practices of mindful eating (ME) and intuitive eating (IE) have been developed to minimize external drivers of energy intake by helping individuals emphasize the sensory properties of foods and internal indicators of hunger and fullness. OBJECTIVE: To enhance understanding about the effect of ME and IE interventions on dietary intake, this systematic review included randomized trials of ME and IE interventions that examined dietary intake, defined as energy intake or diet quality, in adults of varying weight status without a diagnosis of an eating disorder. METHODS: The selection of literature followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review process, in which PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and PsycINFO databases were searched for studies published between January 1980 and November 2019. Studies were included if they met the following criteria: randomized trial design in which 1 arm was an intervention with an ME or IE component and there was at least 1 control or active comparison arm; enrolled participants were of a healthy weight or with overweight or obesity and reported not having an eating disorder (ie, anorexia, bulimia nervosa, or binge eating disorder) or other health conditions in which dietary restrictions were applied; were at least 18 years of age; and outcomes of energy intake or diet quality were reported at baseline and post intervention. The modified Downs and Black checklist was used to assess risk of bias for each study that met inclusion criteria. RESULTS: A total of 13 studies, including 8 investigating ME interventions and 5 investigating IE interventions, represented in 14 articles, were included in the review. Seven of the 9 articles reporting on energy intake did not find significant group differences. Eight of the 12 articles reporting on diet quality did not find significant group differences. The mean bias assessment score was 13.6 out of 28, indicating poor quality. CONCLUSIONS: Little evidence suggests that ME and IE interventions influence energy intake or diet quality. To draw strong conclusions about the effect of ME and IE on dietary intake, future research using study designs of high rigor are needed.

Rationale and protocol for translating basic habituation research into family-based childhood obesity treatment: Families becoming healthy together study.

This publication describes the rationale and protocol, including design, aims, intervention, and measures, of Families Becoming Healthy Together, a randomized clinical trial examining the effect of a limited RED (non-nutrient-dense, energy-dense) food variety prescription delivered within an 18-month family-based behavioral obesity treatment (FBT) on body mass index (BMI) and habituation rate to RED foods. One hundred fifty-six children (ages: 8-12 y; BMI: ≥ 85th percentile-for-age) and a caregiver (BMI: ≥ 25 kg/m2), both with overweight or obesity, will be randomized to one of two, interventions: FBT or FBT + Variety. All participants will receive 29 sessions of FBT and be prescribed the Traffic Light Diet (1000-1500 kcal/day, ≤ 2 RED food servings/day), and a physical activity goal (≥ 60 min/day [child] or 150 min/week [adult] of moderate-vigorous physical activity (MVPA)). FBT + Variety will also identify two RED foods, a dinner entrée and snack food, and develop meal plans that reduce variety of RED foods by regularly consuming these foods and limiting consumption of other RED foods. Measures of anthropometrics, dietary intake, habituation of salivary response to food cues, and physical activity will be assessed at 0, 6, 12, and 18-months. This study translates a line of basic behavioral research examining how dietary variety influences habituation into a dietary prescription that will be tested within an efficacy trial. It is hypothesized that a novel, limited dietary variety prescription within FBT should promote a faster food habituation rate, reducing energy intake and amplifying long-term weight loss in children.

Novel Methodological Considerations Regarding the Use of Visual Analog Scale (VAS) Appetite Questionnaires in Tightly Controlled Feeding Trials.

Visual analog scale (VAS) questionnaires are widely used in nutrition research to assess appetite and subsequent food intake. However, a number of methodological considerations exist. The study aims were to test whether 1) appetite VASs alter subsequent food intake and 2) viewing previous appetite responses influences subsequent responses. Twelve healthy adults (age: 22 ± 3 y; BMI: 22.0 ± 3.1 kg/m2) completed the randomized crossover study. On separate days, participants were provided breakfast preloads and completed appetite VASs every 30 min for 4 h or did not complete the questionnaires. When completing VASs, the participants were shown their previous responses (PR) or were not (No-PR). After 4 h, an ad libitum lunch was provided. Hunger, fullness, desire to eat, and prospective food consumption were not different between PR and No-PR. All data are reported as mean ± SEM. VASs did not affect lunch intake (484 ± 50 kcal) compared with no VASs (500 ± 53 kcal, nonsignificant). Thus, neither past appetite responses nor the use of appetite VASs influenced ingestive behavior in healthy adults. This trial was part of a larger acute, randomized crossover trial registered at clinicaltrials.gov as NCT03154606.

Habitual Breakfast Patterns Do Not Influence Appetite and Satiety Responses in Normal vs. High-Protein Breakfasts in Overweight Adolescent Girls.

Differences in postprandial insulin, glucose, and/or free fatty acid concentrations, following the consumption of breakfast, have been demonstrated to be dependent on habitual breakfast patterns. This study examined the effects of habitual breakfast patterns on postprandial appetite, satiety, and hormonal responses along with daily food intake following the consumption of normal-protein (NP) vs. higher-protein (HP) breakfasts in overweight adolescents. Thirty-seven girls (age: 19 ± 1 year; BMI: 29.0 ± 3.4 kg/m2) participated in the semi-randomized crossover design study. Participants were grouped according to whether they habitually skipped (SKIP, n = 18) or consumed breakfast (CONSUME, n = 19), and consumed a NP (350 kcal; 13 g protein) or HP (350 kcal; 35 g protein) breakfast for 3 days/pattern. On day 4, breakfast was provided, and appetite questionnaires and blood samples were collected throughout an 8 h testing day. Daily food intake was also assessed. Regardless of habitual breakfast patterns, the consumption of HP breakfast led to greater daily fullness (29,030 ± 6,010 min × mm) vs. NP breakfast (26,910 ± 5580 min × mm; p = 0.03). Daily protein consumption was greater (98 ± 15 g vs. 78 ± 15 g), and carbohydrate consumption was lower (331 ± 98 g vs. 367 ± 94 g) with HP vs. NP (both, p < 0.001). No other differences were observed. These data suggest that the recommendation to consume a HP breakfast for improved satiety and ingestive behavior is appropriate for overweight adolescent girls, regardless of habitual breakfast patterns.

A high-protein breakfast prevents body fat gain, through reductions in daily intake and hunger, in "Breakfast skipping" adolescents.

OBJECTIVE: The purpose of this study was to examine whether the daily consumption of normal-protein (NP) vs. high-protein (HP) breakfast meals improves appetite control, food intake, and body composition in "breakfast skipping" young people with overweight/obesity. METHODS: Fifty-seven adolescents (age: 19 ± 1 years; BMI: 29.7 ± 4.6 kg m(-2)) completed a 12-week randomized controlled trial in which the adolescents consumed either a 1,464 kJ NP breakfast (13 g protein) or a HP breakfast (35 g protein) or continued to skip breakfast (CON). Pre- and post-study appetite, food intake, body weight, and body composition were assessed. RESULTS: Time-by-group interactions (P < 0.05) were detected for body fat mass, daily intake, and perceived hunger. Specifically, HP prevented fat mass gains over the 12 weeks (-0.4 ± 0.5 kg) vs. CON (+1.6 ± 0.9 kg; P = 0.02), whereas NP did not (+0.3 ± 0.5 kg). HP led to reductions in daily intake (-1,724 ± 954 kJ) vs. CON (+1,556 ± 745 kJ; P = 0.03), whereas NP did not (+494 ± 213 kJ). Lastly, only the HP group experienced reductions in daily hunger vs. CON (P < 0.05). However, when directly comparing the HP vs. NP groups, no differences were detected in any outcomes. CONCLUSIONS: The daily addition of a HP breakfast improved indices of weight management as illustrated by the prevention of body fat gain, voluntary reductions in daily intake, and reductions in daily hunger in breakfast skipping adolescents with overweight/obesity.

Consuming Beef vs. Soy Protein Has Little Effect on Appetite, Satiety, and Food Intake in Healthy Adults.

BACKGROUND: Although protein-rich plant foods have recently been touted as an equivalent to animal products, limited data exist regarding the effects of animal vs. plant proteins on appetite, satiety, and subsequent food intake. OBJECTIVE: The objective was to determine whether a high-protein beef lunch alters the appetitive, hormonal, and neural signals controlling food intake regulation vs. a macronutrient and fiber-matched (MF) or serving size-matched (SS) soy lunch in healthy adults. METHODS: A randomized, double-blind, crossover design study was completed in 21 adults (aged 23 ± 1 y; body mass index: 23.8 ± 0.6 kg/m²; mean ± SEM) to compare 400-kcal MF and SS lunches varying in protein quality. The MF lunches contained 24-g beef protein or 24-g soy protein, whereas the SS lunches contained 1 serving of beef (24-g protein/1-g fiber) or soy (14-g protein/5-g fiber). Pre- and postlunch appetite questionnaires and blood sampling were completed over an 8-h period until dinner was voluntarily requested. In addition, pre- and postlunch functional MRI brain scans were completed to assess neural activation in response to food stimuli. RESULTS: On average, dinner was requested at ∼250 ± 20 min postlunch with no differences between beef vs. soy within the MF and SS conditions. Furthermore, no differences in hunger, fullness, peptide YY, or glucagon-like peptide-1 responses were observed after the beef vs. soy lunches within the MF and SS conditions. The SS beef meal led to reductions in anterior cingulate activation (-22 ± 6%) vs. soy (+7 ± 9%; P < 0.01) and greater reductions in insular activation (-30 ± 6%) vs. SS soy (-7 ± 10%; P < 0.01). The participants consumed ∼945 ± 78 kcal after the MF meals and 910 ± 74 kcal after the SS meals with no differences between beef vs. soy. CONCLUSIONS: When comparing 2 high-quality protein sources, such as beef and soy, the type of protein consumed within a mixed meal elicited very little effect on appetite, satiety, and food intake in healthy adults.

Effects of high-protein vs. high- fat snacks on appetite control, satiety, and eating initiation in healthy women.

BACKGROUND: The purpose of this study was to determine whether a high-protein afternoon yogurt snack improves appetite control, satiety, and reduces subsequent food intake compared to other commonly-consumed, energy dense, high-fat snacks. FINDINGS: Twenty, healthy women (age: 27 ± 2 y; BMI: 23.4 ± 0.7 kg/m2) completed the randomized crossover design study which included 3, 8-h testing days comparing the following 160 kcal afternoon snacks: high-protein yogurt (14 g protein/25 g CHO/0 g fat); high-fat crackers (0 g protein/19 g CHO/9 g fat); and high-fat chocolate (2 g protein/19 g CHO/9 g fat). Participants were acclimated to each snack for 3 consecutive days. On day 4, the participants consumed a standardized breakfast and lunch; the respective snack was consumed 3-h post-lunch. Perceived hunger and fullness were assessed throughout the afternoon until dinner was voluntarily requested. An ad libitum dinner was then provided. The consumption of the yogurt snack led to greater reductions in afternoon hunger vs. chocolate (p < 0.01). No differences in afternoon fullness were detected. The yogurt snack also delayed eating initiation by approximately 30 min compared to the chocolate snack (p < 0.01) and approximately 20 min vs. crackers (p = 0.07). The yogurt snack led to approximately 100 fewer kcals consumed at dinner vs. the crackers (p = 0.08) and chocolate (p < 0.05). No other differences were detected. CONCLUSION: These data suggest that, when compared to high-fat snacks, eating less energy dense, high-protein snacks like yogurt improves appetite control, satiety, and reduces subsequent food intake in healthy women.

The effects of increased dietary protein yogurt snack in the afternoon on appetite control and eating initiation in healthy women.

BACKGROUND: A large portion of daily intake comes from snacking. One of the increasingly common, healthier snacks includes Greek-style yogurt, which is typically higher in protein than regular yogurt. This study evaluated whether a 160 kcal higher-protein (HP) Greek-style yogurt snack improves appetite control, satiety, and delays subsequent eating compared to an isocaloric normal protein (NP) regular yogurt in healthy women. This study also identified the factors that predict the onset of eating. FINDINGS: Thirty-two healthy women (age: 27 ± 2y; BMI: 23.0 ± 0.4 kg/m2) completed the acute, randomized crossover-design study. On separate days, participants came to our facility to consume a standardized lunch followed by the consumption of the NP (5.0 g protein) or HP (14.0 g protein) yogurt at 3 h post-lunch. Perceived hunger and fullness were assessed throughout the afternoon until dinner was voluntarily requested; ad libitum dinner was then provided. Snacking led to reductions in hunger and increases in fullness. No differences in post-snack perceived hunger or fullness were observed between the NP and HP yogurt snacks. Dinner was voluntarily requested at approximately 2:40 ± 0:05 h post-snack with no differences between the HP vs. NP yogurts. Ad libitum dinner intake was not different between the snacks (NP: 686 ± 33 kcal vs. HP: 709 ± 34 kcal; p = 0.324). In identifying key factors that predict eating initiation, perceived hunger, fullness, and habitual dinner time accounted for 30% of the variability of time to dinner request (r = 0.55; p < 0.001). CONCLUSIONS: The additional 9 g of protein contained in the high protein Greek yogurt was insufficient to elicit protein-related improvements in markers of energy intake regulation.

Beneficial effects of a higher-protein breakfast on the appetitive, hormonal, and neural signals controlling energy intake regulation in overweight/obese, "breakfast-skipping," late-adolescent girls.

BACKGROUND: Breakfast skipping is a common dietary habit practiced among adolescents and is strongly associated with obesity. OBJECTIVE: The objective was to examine whether a high-protein (HP) compared with a normal-protein (NP) breakfast leads to daily improvements in appetite, satiety, food motivation and reward, and evening snacking in overweight or obese breakfast-skipping girls. DESIGN: A randomized crossover design was incorporated in which 20 girls [mean ± SEM age: 19 ± 1 y; body mass index (in kg/m(2)): 28.6 ± 0.7] consumed 350-kcal NP (13 g protein) cereal-based breakfasts, consumed 350-kcal HP egg- and beef-rich (35 g protein) breakfasts, or continued breakfast skipping (BS) for 6 d. On day 7, a 10-h testing day was completed that included appetite and satiety questionnaires, blood sampling, predinner food cue-stimulated functional magnetic resonance imaging brain scans, ad libitum dinner, and evening snacking. RESULTS: The consumption of breakfast reduced daily hunger compared with BS with no differences between meals. Breakfast increased daily fullness compared with BS, with the HP breakfast eliciting greater increases than did the NP breakfast. HP, but not NP, reduced daily ghrelin and increased daily peptide YY concentrations compared with BS. Both meals reduced predinner amygdala, hippocampal, and midfrontal corticolimbic activation compared with BS. HP led to additional reductions in hippocampal and parahippocampal activation compared with NP. HP, but not NP, reduced evening snacking of high-fat foods compared with BS. CONCLUSIONS: Breakfast led to beneficial alterations in the appetitive, hormonal, and neural signals that control food intake regulation. Only the HP breakfast led to further alterations in these signals and reduced evening snacking compared with BS, although no differences in daily energy intake were observed. These data suggest that the addition of breakfast, particularly one rich in protein, might be a useful strategy to improve satiety, reduce food motivation and reward, and improve diet quality in overweight or obese teenage girls. This trial was registered at clinicaltrials.gov as NCT01192100.

Low, moderate, or high protein yogurt snacks on appetite control and subsequent eating in healthy women.

This study assessed whether afternoon snacks, varying in protein content, influence appetite-control and eating initiation. Fifteen healthy women (age: 26 ± 2 y) randomly consumed 160 kcal afternoon yogurt snacks containing Low (LP), Moderate (MP), or High (HP) protein (5,14,24 g protein, respectively) or had no snack (NS) for 3 days. On day 4, the volunteers came to our facility to consume a standardized lunch. The respective snack pattern was completed 3h post-lunch. Perceived sensations were measured every 30 min until dinner was voluntarily requested. An ad libitum dinner was then provided. Snacking, regardless of protein content, led to reduced hunger and increased fullness, which were sustained up to 120 min post-snack vs. NS (all, p<0.05). Between snacks, hunger was lower and fullness was higher throughout post-snack following HP vs. LP (p<0.05). Snacking delayed the onset of eating vs. NS (all, p<0.05). Specifically, dinner was requested at 124 ± 7 min following NS, 152 ± 7 min with LP, 158 ± 7 min following MP, and 178 ± 7 min post-snack for HP. Between snacks, HP led to the latest request time vs. LP (p<0.001) and MP (p<0.05). Although the energy content consumed at dinner was lower following the yogurt snacks vs. NS, the 160 kcal snacks were not fully compensated for at this meal. In conclusion, an afternoon snack of Greek yogurt, containing 24 g protein, led to reduced hunger, increased fullness, and delayed subsequent eating compared to lower protein snacks in healthy women.