A 40-year-old woman comes to the office to discuss nutrition. She says, "I have been overweight since the birth of my third child 10 years ago, and none of the diets I have tried ever seem to help." The patient reduced her food intake by 100-200 kcal/day on a restricted-fat diet 4 weeks ago, but her weight has not changed. She says, "I want to make sure I am doing the right thing. I tried to read about diets on the internet but I don't know what to believe." Medical history is notable for hypothyroidism, treated with a stable dose of levothyroxine. She does not smoke and drinks alcohol on social occasions only. Family history is significant for breast cancer and coronary artery disease in her mother and colon cancer in her father. Vital signs are normal. BMI is 32 kg/m². The thyroid is normal to palpation. Cardiopulmonary examination is normal. The abdomen is soft and nontender with no hepatomegaly. Deep tendon reflexes are normal and symmetric. Serum TSH is 2.1 µU/mL. Which of the following is the most appropriate nutritional recommendation for this patient?

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Explanation: 11ec2b69_bf46_c7af_8f63_3dc5054dd849_MD0005_00 Patients who are obese are at increased risk for cardiovascular disease, hypertension, diabetes mellitus, and cancer, but weight loss of 5%-7% from baseline can confer a demonstrable reduction in risk. The following diets have been shown to reduce the risk of cardiovascular disease and are associated with moderate weight reduction in obese patients: Mediterranean diet - high in fruits, vegetables, whole grains, beans, nuts, and seeds with low/moderate intake of fish, poultry, dairy, and red wine. Olive oil is prominently featured and red meat and saturated fats are generally avoided. Dietary Approaches to Stop Hypertension (DASH) diet - high in fruits, vegetables, whole grains, and low-fat dairy, with low/moderate intake of lean meats, nuts, seeds, and legumes. Vegetarian, low-fat, and low-carbohydrate diets can also be helpful in weight loss, although evidence for cardioprotective effects is not as strong as for the Mediterranean and DASH diets. Once this patient determines which approach is preferred, supportive follow-up may be helpful, as weight loss correlates more closely with patient adherence and overall behavior modification (eg, exercise habits, food-eating triggers) than with the specific macronutrient content of the diet chosen (Choice C). (Choice A) Diets high in dietary fiber are associated with a lower risk of cardiovascular disease, cancer (eg, breast, colon), diabetes mellitus, and all-cause mortality. Processed fiber supplements, however, have not shown the same benefit. (Choice B)Most diets used for weight loss (eg, low-fat, DASH, Mediterranean, nonvegan vegetarian) are not associated with increased risk of vitamin D deficiency or fracture. By contrast, patients on strict vegan diets or who undergo surgical procedures for weight reduction often require vitamin D supplementation to prevent fracture. (Choice D) Although the "3,500 kcal rule" predicts that a deficit of 3,500 kcal (eg, 500 kcal/day for a week) will yield a 0.45 kg (1 lb) weight loss, observed weight loss is usually much less due to metabolic and behavioral compensation (eg, reduced activity). Educational objective: Diets (eg, Mediterranean, DASH) high in fruits, vegetables, whole grains, lean meats, and low-fat dairy and low in red/processed meats and saturated fats have been shown to reduce the risk of heart disease, and can induce moderate weight loss in obese patients. References: Nutrition myths and healthy dietary advice in clinical practice. (http://www.ncbi.nlm.nih.gov/pubmed/25955738)

A 40-Year-Old Woman Comes to the Office to Discuss Nutrition