The Science Supporting PHD Client Success
Obesity has reached epidemic proportions in The United States and around the globe. In 2018 the prevalence of obesity was 42.4%1 with 75% of Americans being reported as overweight. Diabetes and Prediabetes have increased in step with obesity and together makeup nearly 50% of the American adult population2. Obesity, particularly central obesity, is closely associated with diabetes and metabolic syndrome3. Insulin resistance, the hallmark of diabetes, is the physiologic component connecting the defining characteristics of metabolic syndrome and obesity4. Metabolic syndrome is associated with a 2-fold increased risk of cardiovascular disease5, increased cancer risk6 and Alzheimer’s Disease risk7 as well as many other common chronic diseases.
Medically accepted treatments for obesity generally include calorie restriction, dietary fat restriction, exercise, hormones and bariatric surgery. Failure rates for nutrition and exercise approaches are unacceptably high and rates of insulin resistance related diseases continue to increase. Bariatric surgery represents a last resort, permanent alteration in gastrointestinal function that has variable rates of success, complication and failure secondary to weight regain.
A novel approach to weight loss and maintenance was created by Dr. Ashley Lucas, PhD, RD and put into clinical practice in 2015. The PHD Weight Loss Approach (PHD) is an approach created to cultivate individualized weight management WITHOUT severe caloric restriction, chronic exercise, surgery, shots, drops, or supplements. PHD provides an integrative and intensive method unique from other programs and surgical approaches. We utilize body composition analysis, nutrient timing, nutrition education, optional performance food products to assist in ease of meal planning early on, lymphatic support, stress mastery techniques, and Cognitive Behavioral Therapy (CBT) to help our clients achieve their goals. The dietary and lifestyle practices that we recommend are unique to each person. We also understand that weight maintenance is where the work lies and support such effort with a free maintenance program. We recognize that we are in the profession of addiction recovery and that constant support and accountability once goals are achieved are imperative for long term maintenance success.
Methods and Materials:
To validate the PHD approach to weight loss a retrospective review was performed on client charts from January 2016 to April 2019 with 2 goals. First, to explore the success of the weight loss phase of the program and second, to identify the success of the maintenance phase. Success of weight loss was defined as percentage of clients that reached their PHD approach determined optimal body alignment. Success of maintenance was defined as the percentage of active participants that maintained their weight loss over time.
At the time of chart review 1,350 clients had started with PHD. 192 clients were in the active phase of weight loss leaving 1,158 client charts for review. We identified 1,107 clients that had completed their program and 51 that discontinued. Optimal body alignment was determined by a commercial grade body composition scale (Tanita.com) that is within 5% of gold standard (DEXA scan). To put this into perspective we compared the PHD optimal body composition weight loss goals to the previously defined excess weight loss (EWL) goal used in bariatric surgery literature8. Excess Weight (EW) is defined as current weight minus expected body weight at BMI of 25. Excess weight loss is then the percentage of weight lost divided by the total EW.
Active maintenance participant charts were available for review. 149 charts were reviewed including a subgroup of 31 participants that started with a BMI greater than 30. Rates of relapse, as defined as regaining 10% of the participants optimal weight after achieving maintenance, was calculated for all active maintenance participants as well as the smaller subgroup (n=39) of BMI>30 at program start.
1,158 participants had either completed their program or discontinued. 1,107 (95.6%) successfully achieved optimal body alignment while 51 (4.4%) discontinued their program. EWL was evaluated for the BMI >30 subgroup for accurate comparison to patients eligible for bariatric surgery. The EWL was 108% in this subgroup with an overage loss of over 56 pounds and a range of 22 – 110 pounds lost.
Maintenance performance was available for 149 participants with an average follow up of nearly 12 months (347 days). 20 (13.4%) participants had restarted their program for failure to maintain their ideal body composition leaving 129 (86.6%) who had successfully maintained their weight in maintenance. There were 39 participants in the BMI>30 subgroup of which 8 (20.5%) relapsed.
|Table 1: All Active Maintenance Participants|
|Table 2: Maintenance Participants BMI>30|
|Starting BMI||33.86 (30.2-43.0)|
|Ending BMI||24.5 (21.8-27.7)|
|EWL (Excess Weight Lost)||108% (68-145)|
The PHD approach of individualized nutrition and behavioral therapy is highly successful for both weight loss and weight maintenance. Numerous approaches to weight loss are publicly available but traditional medical approaches typically include severe calorie restriction, increased exercise, dietary fat restriction, hormone therapy and ultimately bariatric surgery. A substantial body of literature is available for comparison of these approaches.
Severe calorie restriction, low calorie diets and very low-calorie diets (VLCD) are popular approaches because they result in rapid weight loss. Numerous studies demonstrate the ability to lose weight initially, but weight regain appears to be “inevitable.”10 In a 2002 study comparing VLCD to conventional calorie restriction VLCD demonstrated rapid weight loss after a 6-week program but complete failure of maintenance by 5 years with no significant weight loss remaining from baseline. Fothergill studied contestants from The Biggest Loser 6 years after program completion11. Only 30% of the weight lost during the program was maintained on average and 5 out of 14 contestants gained all of their weight back or more. The authors also examined basal metabolic rate (BMR) which declined with weight loss more than expected when adjusted for lean muscle mass. After 6 years the BMR not only didn’t recover but continued to decline. This study demonstrates that even with aggressive exercise to combat loss of lean muscle mass BMR continued to drop with severe calorie restriction and weight maintenance was not possible except for 1/14 (7%) of participants. This single participant notably lost the least amount of weight during the program initially which likely preserved BMR and allowed for continued success.
Exercise is often recommended as a weight loss tool and universally included in lifestyle changes aimed at weight loss and weight maintenance. In a 12-month randomized trial exercise alone was compared to a low-fat diet, diet and exercise together and controls12. 114 participants randomized to the exercise alone group lost only 4.4lbs (2.0% of body weight) on average after 12 months. These results were inferior to diet combined with exercise for the short term but the follow up study demonstrated failure of all groups to maintain weight loss over the subsequent 18 months13.
Dietary fat restriction by itself is theorized to result in weight loss due to substitution of a macronutrient with fewer calories per gram (protein or carbohydrate). In the well-known Women’s Health Initiative Dietary Modification Trial14 48,835 women were randomized to a dietary fat restricted approach for 7.5 years. The intervention resulted in a loss of 1.8 pounds (1.04% of body weight) and failed to prevent an increase in waist circumference during the trial which is closely associated with metabolic syndrome and arguably more important than a 1% loss of body weight.
Human Chorionic Gonadotropin (HcG) has been used for weight loss since the 1950’s. The hormone is paired with a VLCD of 500 kcal per day with the expectation that the hormone will make the calorie restriction more tolerable and possibly prevent loss of lean muscle mass. Numerous studies have been performed that have failed to confirm this hypothesis15. There also appears to be risks associated with adding this hormone out of sync with its physiologic purpose. Hormone Replacement Therapy (HRT) and Bioidentical HRT (BHRT) have both been touted as methods to assist in weight loss programs. A review of the literature produced no studies looking at weight loss as an end point for this approach.
Lastly, bariatric surgery has become an increasingly appealing option for patients that have failed numerous attempts at weight loss and maintenance. Bariatric surgery literature reports variable success measures but 30-50% of EWL appears to be a consistent aim. Failure of weight loss is consistently defined as inability to maintain >25% EWL at follow up. Unfortunately, even aggressive surgical intervention has a failure rate of >50%16. Surgical complications include chronic anemia in 64% at 3 years, malabsorption, nutritional deficiencies, adhesions and even death17,18. While surgical intervention may be the best answer for some patients it must be considered a last option after all nutrition and behavioral approaches are exhausted. Even then, the nutrition and behavioral approaches must be incorporated to prevent failure of weight loss maintenance.
Weaknesses of this study are many. PHD is not an academic center or physician office. At the time of the study charting was all on paper and client health profiles were not rigorously reviewed. Medical diagnosis were screened for medical clearance but not followed for changes during their program. The average follow-up of just under 12 months provides only early data to examine. Further analysis of the PHD approach with more rigorous methods would allow for comparison of medical diagnosis resolution, medication changes and vital sign/lab value improvement as well as long term success. Changes in data management and physician partnership have allowed for improved opportunities for future research. Anecdotally, PHD clients see similar or superior results to published data on resolution of diabetes and signs/symptoms of metabolic disease.
In conclusion, the PHD approach to weight loss and maintenance provides an individualized approach to nutrition and incorporates behavioral therapy to achieve high rates of success. 95.6% of clients reached optimal body alignment and 86.6% of all active maintenance clients were able to successfully maintain their weight loss for 12 months. The subgroup of BMI>30 had a slightly lower success rate of 79.5% in maintenance. Lifestyle modifications including low-fat diets and exercise fail to generate significant weight loss. Calorie restriction produces significant weight loss but reliably reduces BMR making maintenance very unlikely and generating metabolic damage that makes future weight loss efforts more difficult. Bariatric surgery candidates are also initially successful and lose between 30-50% of EWL during follow up but with high rates of maintenance failure and complication. In comparison PHD clients with BMI>30 achieved optimal body alignment with 108% EWL and with 79.5% maintaining weight during early follow up. The PHD approach is a safe way to achieve optimal body alignment and support long term success.
Supporting your Performance, Health, Diet, PHD
Douglas E Lucas, DO
Chief Science Officer
PHD Weight Loss and Nutrition
- Després, J., & Lemieux, I. (2006). Abdominal obesity and metabolic syndrome. Nature, 444(7121), 881-887.
- Barazzoni R, Gortan Cappellari G, Ragni M, Nisoli E. Insulin resistance in obesity: an overview of fundamental alterations. Eat Weight Disord. 2018;23(2):149-157. doi:10.1007/s40519-018-0481-6
- Mottillo S, Filion KB, Genest J, et al. The metabolic syndrome and cardiovascular risk a systematic review and meta-analysis. J Am Coll Cardiol. 2010;56(14):1113-1132. doi:10.1016/j.jacc.2010.05.034
- Esposito K, Chiodini P, Colao A, Lenzi A, Giugliano D. Metabolic syndrome and risk of cancer: a systematic review and meta-analysis. Diabetes Care. 2012;35(11):2402-2411. doi:10.2337/dc12-0336)
- Serrano-Pozo A, Growdon JH. Is Alzheimer’s Disease Risk Modifiable?. J Alzheimers Dis. 2019;67(3):795-819. doi:10.3233/JAD181028
- O’brien et al, Long-Term Outcomes After Bariatric Surgery: Fifteen Year Follow-Up of Adjustable Gastric Banding and a Systematic Review of the Bariatric Surgical Literature. Annals of Surgery, January 2012.
- Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction. 2004;99(1):29-38. doi:10.1111/j.1360-0443.2004.00540.x
- Paisey RB, Frost J, Harvey P, et al. Five year results of a prospective very low calorie diet or conventional weight loss programme in type 2 diabetes. J Hum Nutr Diet. 2002;15(2):121-127. doi:10.1046/j.1365-277x.2002.00342.x
- Fothergill E, Guo J, Howard L, et al. Persistent metabolic adaptation 6 years after “The Biggest Loser” competition. Obesity (Silver Spring). 2016;24(8):1612-1619. doi:10.1002/oby.21538
- Foster-Schubert KE, Alfano CM, Duggan CR, et al. Effect of diet and exercise, alone or combined, on weight and body composition in overweight-to-obese postmenopausal women. Obesity (Silver Spring). 2012;20(8):1628-1638. doi:10.1038/oby.2011.76
- Duggan C, Tapsoba JD, Stanczyk F, Wang CY, Schubert KF, McTiernan A. Long-term weight loss maintenance, sex steroid hormones, and sex hormone-binding globulin. Menopause. 2019;26(4):417-422. doi:10.1097/GME.0000000000001250.
- Howard BV, Manson JE, Stefanick ML, et al. Low-fat dietary pattern and weight change over 7 years: the Women’s Health Initiative Dietary Modification Trial. JAMA. 2006;295(1):39-49. doi:10.1001/jama.295.1.39
- Butler SA, Cole LA. Evidence for, and Associated Risks with, the Human Chorionic Gonadotropin Supplemented Diet. J Diet Suppl. 2016;13(6):694-699. doi:10.3109/19390211.2016.1156208
- Azagury D, Mokhtari TE, Garcia L, et al. Heterogeneity of weight loss after gastric bypass, sleeve gastrectomy, and adjustable gastric banding. Surgery. 2019;165(3):565-570. doi:10.1016/j.surg.2018.08.023
- Vargas-Ruiz AG, Hernández-Rivera G, Herrera MF. Prevalence of iron, folate, and vitamin B12 deficiency anemia after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2008;18(3):288-293. doi:10.1007/s11695-007-9310-0
- O’Brien PE, MacDonald L, Anderson M, Brennan L, Brown WA. Long-term outcomes after bariatric surgery: fifteen-year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature. Ann Surg. 2013;257(1):87-94. doi:10.1097/SLA.0b013e31827b6c02