We applaud Yancy and colleagues1 trial examining the impact of diet choice on weight loss. The trial's focus on behavioral determinants is a refreshing contrast ...
24/8/2015
Effect of Allowing Choice of Diet on Weight Loss: A Randomized TrialEffect of Allowing Choice of Diet on Weight Loss | Annals of Internal Medicine
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Original Research | 16 June 2015
Effect of Allowing Choice of Diet on Weight Loss: A Randomized Trial William S. Yancy Jr., MD; Stephanie B. Mayer, MD; Cynthia J. Coffman, PhD; Valerie A. Smith, DrPH; Ronette L. Kolotkin, PhD; Paula J. Geiselman, PhD; Megan A. McVay, PhD; Eugene Z. Oddone, MD; and Corrine I. Voils, PhD [+] Article, Author, and Disclosure Information Ann Intern Med. 2015;162(12):805814. doi:10.7326/M142358
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Posted on June 24, 2015
Sherry L. Pagoto, PhD, Brad Appelhans University of Massachusetts Medical School and Rush University Medical Center
Conflict of Interest: None Declared We applaud Yancy and colleagues1 trial examining the impact of diet choice on weight loss. The trial’s focus on behavioral determinants is a refreshing contrast to the multitude of prior diet comparison studies that have failed to support the superiority of any one particular diet for weight loss.2 The hypothesis for this trial was that patient choice of diet (lowfat vs lowcarb) may promote diet adherence, and therefore improve weight loss, compared to when diets are randomly assigned.3 Based on the lack of a difference in weight loss between the Choice Group and Assigned Diet Group, the authors conclude that “the opportunity to choose a diet did not improve weight loss.” However, it appears that patients’ diet choices were made only after being counseled by interventionists to choose the diet most consistent with their dietary preferences, which were assessed upon enrollment. Indeed, over 70% of subjects in the Choice Group chose the diet that matched their food preferences. While providing information that enables patients to make an informed choice is consistent with shared decision making, actively promoting concordance between one’s food preferences and diet plan may have skewed the decision making process. We do not know what choice the participant would have made without counseling or with a different counseling approach. In fact, one could argue for counseling participants toward the opposing perspective of choosing a diet plan that minimizes exposure to temptation from preferred foods. The fact that most subjects in the Choice Group aligned their diet plans with their food preferences suggests that the effects of choice and the counseling procedures were conflated. It is also noteworthy that participants’ food preferences were categorized based on macronutrient content. Whether human food preferences strongly cluster according to macronutrient content, rather than other factors such as palatability, texture, sweet versus savory, flavors, or form is unknown. While the proportion of subjects classified into highcarbohydrate and highprotein preference groups is reported, the strength of these preferences is not. As diet choice appears to have been intentionally tied to macronutrient preferences, the lack of differences between the choice groups may simply reflect a lack of strong
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24/8/2015
Effect of Allowing Choice of Diet on Weight Loss: A Randomized TrialEffect of Allowing Choice of Diet on Weight Loss | Annals of Internal Medicine
macronutrient preferences. Yancy et al.’s investigation underscores the need for behavioral research that sheds light on the factors driving choice that actually lead to improved dietary adherence and weight loss; otherwise it is difficult to know how to counsel patients on how to make an informed choice. 1. Yancy WS, Jr., Mayer SB, Coffman CJ, et al. Effect of Allowing Choice of Diet on Weight Loss: A Randomized Trial. Ann. Intern. Med. Jun 16 2015;162(12):805814. 2. Pagoto SL, Appelhans BM. A call for an end to the diet debates. JAMA. Aug 21 2013;310(7):687688. 3. Yancy WS, Jr., Coffman CJ, Geiselman PJ, et al. Considering patient diet preference to optimize weight loss: Design considerations of a randomized trial investigating the impact of choice. Contemp Clin Trials. May 2013;35(1):106116.
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PubMed Articles Comment
Posted on July 6, 2015
Daniel LópezHernández, PhD CENINVEC, Mexico
Conflict of Interest: None Declared I read with great interest the recently article published by Yancy et al., (1) where authors examining the impact of diet choice on weight loss using a doublerandomized preference trial.
LowGlycemic Index Diet May Improve Insulin Sensitivity in Obese Children. Pediatr Res Published online Aug 13, 2015; Parents' perspective on weight management interventions for adolescents with intellectual and developmental disabilities. Disabil Health J Published online Jul 23, 2015; View More
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Although the authors did not find significant difference on mean weight loss between the choice group and the comparator group, this study opened a new hypothesis and questions about the actual influence of existing nutritional programs and the possibility to incorporate new programs basedon the patient´s empowerment. The present study raises several questions about the control of variables such as the educational intervention sessions, dietary preferences, shared decision making, the counseling approach, the number of educational sessions necessary to impact in reducing the weight of patients. Empowerment refers to the ability of a person to develop and acquire cognitive behavioral tools that allow he or she change their lifestyle to display the ability to live on behaviors that promote health employing the resources of their environment. Therefore, what type of information enables patients to make an informed choice on their election of diet?, what kind of variables can bias the decisionmaking process?, what is the influence of family and environment in the dietary preference of patients? The patient empowerment could influence the develop of new Models of Primary Health Care for the development of prevention strategies?, How the medication adjustment affects weight loss?, how the medication interacts with diet for control of weight loss and other variables?
In conclusion, the present study allows us to observe that there are more issues that need to be taken into consideration health public systems for nutritional programs and the clinical practice guidelines. More studies like this are needed to answer more questions.
References 1. Yancy WS Jr, Mayer SB, Coffman CJ, et al. Effect of Allowing Choice of Diet on Weight Loss: A Randomized Trial. Ann Intern Med. 2015;162(12):80514.
2. Mantwill S, Fiordelli M, Ludolph R, Schulz PJ. EMPOWERsupport of patient empowerment by an intelligent selfmanagement pathway for patients: study protocol. BMC Med Inform Decis Mak. 2015;15:18.
3. Thesen J. From oppression towards empowerment in clinical practiceoffering doctors a model for reflection. Scand J Public Health Suppl 2005; 66: 4752.
4. Aveiro M, Santiago LM, Lopes Ferreira P, Simões JA. Fiability Study of Diabetes Empowerment Scale: Short Version. Acta Med Port. 2015;28(2):17781. [Article in Portuguese].
5. Rossi MC, Lucisano G, Funnell M, et al. Interplay among patient empowerment and clinical and person centered outcomes in type 2 diabetes. The BENCHD study. Patient Educ Couns. 2015;pii: S0738 3991(15)002335.
Response to Pagoto and Appelhans
Posted on August 3, 2015
William S. Yancy, Jr., Megan A. McVay, Corrine I. Voils
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24/8/2015
Effect of Allowing Choice of Diet on Weight Loss: A Randomized TrialEffect of Allowing Choice of Diet on Weight Loss | Annals of Internal Medicine
Center for Health Services Research in Primary Care, Department of Veterans Affairs, and Duke University Medical Center, Durham, North Carolina
Conflict of Interest: None Declared We greatly appreciate the supportive comments from Pagoto and Appelhans regarding our study. We agree with their point that the effects of choice and the counseling procedures were conflated—indeed, this will always be the case if counseling is provided to a person faced with a choice. To clarify our study procedures, however, participants were not advised to select “the diet most consistent with their dietary preferences.” (1) Instead, we encouraged them to use all information provided and any additional information they obtained on their own when making their choice, and although food preference information was provided, they were explicitly informed that they could choose a diet consistent with or opposite of their food preferences. This is evidenced by the 29% who selected the diet that was not most closely aligned with their food preferences. Furthermore, when asked the reason for their diet selection, participants rated several factors as similar or of greater importance than food preferences, including perceptions of diet effectiveness and the description of diets provided (2).We also agree with the second point that other factors besides macronutrient content may drive food preferences. For this reason, we described the diets in detail to participants, listing potential food items and menus for each diet. Therefore, the participants were provided a comprehensive picture of the two diets on which to base their decision using any food preference factors (or other factors, e.g., health, cost, convenience) that were important to them. Finally, we wholeheartedly agree that more data is needed on the factors “driving choice that actually lead to improved dietary adherence and weight loss” and we are currently conducting followup analyses to answer that question. 1. Pagoto SL, Appelhans B. Comment. Ann Intern Med. 2015;XX:xxxxxx. 2. McVay MA, Voils CI, Coffman CJ, Geiselman PJ, Kolotkin RL, Mayer SB, Smith VA, Gaillard L, Turner MJ, Yancy WS Jr. Factors associated with choice of a lowfat or lowcarbohydrate diet during a behavioral weight loss intervention. Appetite. 2014;83:117124. Submit a Comment
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