LIFESTYLE INTERVENTIONS FOR NON-ALCOHOLIC FATTY LIVER DISEASE

Kirsten Coppell, Public Health Physician Senior Research Fellow, Department of Medicine, University of Otago; Training Programme Supervisor, NZCPHM

Principles of Healthy Eating

In 9 words….. • Eat less • Move more • Eat mostly fruits and vegetables

For additional clarification – a 5 word modifier……

• Go easy on junk foods

Nestle, Marion (2006). What to Eat. New York: North Point Press (Farrar, Straus and Giroux). ISBN 978-0-86547-738-4. HOW?

How much does surgery cost?

Weight Loss Surgery Fees Initial Consultation $280 Gastric Banding Surgery $18,500 Gastric Sleeve Surgery $20,750 Gastric Bypass Surgery $23,500 Additional Fees The Optifast pre-surgery replacement must be purchased separately from your local pharmacy. Other additional costs may include staying extra nights in hospital, extra theatre time, blood transfusion and/or x-rays. PLEASE NOTE: 99% of patients do not incur additional costs. Based on these costs……… To provide BS for 192,000 210,000 with BMI ≥40kg/m2 @ $20,000 per operation = $3,840,000,000 $4,200,000,000 $74.46M

PHARMAC 2017 Year in Review 570,000

PHARMAC 2016 Year in Review The prevalence of overweight and in NZ adults by age group, 2016/17. 100 Overweight Obesity 90 80 70 60 39.3 32.4 37.2 38.4 27.0 50 31.1 40 24.0 30 14.7

Proportion (%)Proportion 12.3 20 10 0 0-14 15-17 18-24 25-34 35-44 45-54 55-64 65-74 75+ Age Groups Ministry of Health. Annual Update of Key Results 2016/17: New Zealand Health Survey. Ministry of Health; 2017. Diabetes and age-specific rates for NZ men and women aged 15 years and over.

Prediabetes - men Diabetes - men Prediabetes - women Diabetes -women 60

50

40

30

Prevalence (%) Prevalence 20

10

0 15-24 25-34 35-44 45-54 55-64 65-74 75+

Coppell K et al. NZ Med J, 2013 Age groups (years) Proportion of women giving birth, by body mass index (BMI) category at first registration with their primary maternity care provider, 2008-2015.

Ministry of Health. Report on Maternity 2015. Wellington: Ministry of Health; 2017. Non-alcoholic fatty liver disease (NAFLD) in NZ ??? The elevated ALT and GGT rates by body mass index category and glucose metabolism disorders for men and women aged 15+ years

Men (n=1,327) Women (n=1,708) ALT % (95% CI) GGT % (95% CI) ALT % (95% CI) GGT % (95% CI) Body mass index category (kg/m2) Normal 7.7 (3.6-11.8) 7.1 (3.4-10.9) 4.9 (2.6-7.2) 6.6 (4.0-9.2) Overweight 15.8 (11.0-20.6) 12.0 (8.4-15.6) 10.5 (6.5-14.6) 15.1 (10.8-19.4) Obese 28.5 (21.7-35.4) 20.9 (15.7-26.1) 16.0 (11.4-20.5) 23.3 (18.3-28.4) Glucose metabolism disorder Normal 16.0 (12.0-20.0) 10.1 (7.4-12.9) 7.1 (5.0-9.2) 10.0 (7.6-12.5) Prediabetes 17.3 (11.5-23.1) 16.3 (11.3-21.3) 15.7 (10.6-20.9) 20.9 (15.6-26.2) Diabetes 23.1 (12.8-33.4) 26.2 (16.7-35.6) 15.2 (7.3-23.0) 36.5 (26.0-47.0)

Coppell KJ, Miller JC, Gray AR, Schultz M, et al. Obesity Science and Practice, 2015. ANZLT Registry Report 2017 Clinical Guidelines for Weight Management in New Zealand Adults

Ministry of Health, Clinical Trials Research Unit. 2009. Clinical Guidelines for Weight Management in New Zealand Adults. Wellington: Ministry of Health.

Annual number of publications on weight loss, 1859-2018

8000

7000

6000

5000

4000 Number 3000

2000

1000

0

1957 1975

1951 2017

1935

1972

1978 1987

2011

1918 1981

1914 1932

1938

1963 1993

1925

1859

1945 1954

2014

1928

1942

1908

1948 1984

1960 1990

2005

1966 1969 1996 1999

2002 2008 Year

List of ‘fad’ diets

• The 4-Hour Body • Macrobiotics • diet

• 5:2 diet • • High carb/low fat diets • Dr. : Eat More, Weigh • • [] Less • • Baby Food Diet] • The Good Carbohydrate Revolution • the Pritikin Principle • diet • • • • Pritikin Diet • • Detox diet • Scarsdale medical diet • Suzanne Somers’ Somersizing

• • • Liquid diets • Cambridge Diet • Gluten fee diet, while essential for • diet people with coeliac disease or gluten • Slim-Fast sensitivity, has also been a fad. • • Diet pills, supplements and herbal • • Ketogenic diet remedies • Dexatrim Natural • Israeli Army diet • Low-carbohydrate diets • HCG diet • • Juice • Hydroxycut • Sugar Busters • Metabolife 356 • KE diet • https://en.wikipedia.org/wiki/Fad_diet#cite_note-Nestle2006-11

Diabetes Diabetes Prevention Prevention Program Study (DPP) (DPS) Finnish Diabetes Prevention Study (DPS)

Intensive lifestyle intervention reduced incidence of diabetes by 58% compared with standard lifestyle recommendations over an average follow-up 3.2 years

Lifestyle goals • to achieve BMI <25 kg/m2 • individualised counselling aimed at: reducing weight reducing intake of total fat & saturated fat increasing dietary fibre, and increasing physical activity Diabetes Prevention Program (DPP)

Intensive lifestyle intervention reduced incidence of diabetes by 58%, and metformin by 31% compared with standard lifestyle recommendations over an average follow-up 2.8 years

Lifestyle goals • to achieve and maintain weight reduction of at least 7% through healthy low calorie, low-fat diet • to engage in physical activity of moderate intensity, such as brisk walking, for at least 150 minutes per week Effect of weight loss on NASH study Intensive weight loss intervention based on strategies used successfully in the DPP, Look AHEAD study and behavioural trials. After 48 weeks intervention group lost an average of 9.3% of their body weight vs 0.2% in the control group, and their NASH activity score improved significantly from 4.4 to 2.0 compared with 4.9 to 3.5 in the control group (p=0.05).

Lifestyle goals • 7-10% weight loss within 6 months then maintain through low calorie and low fat • to engage in physical activity of moderate intensity, such as brisk walking, for at least 150 minutes per week increasing to 200 minutes per week by 6 months

Promrat K, Kleiner DE, Niemeier HM, et al. Hepatology. 2010;51(1):121-9. doi: 10.1002/hep.23276. Diabetes risk in the DPP by percent weight loss

achieved at 6 months (mean follow-up 2.7 years) Adjusted Adjusted Hazard Ratio

51%

Maruther et al. J Gen Intern Med 2013; 28: 1629-36 Diabetes risk in the DPP by percent weight loss achieved at 6 months (mean follow-up 2.7 years)

13% 6% Maruther et al. J Gen Intern Med 2013; 28: 1629-36 How was the lifestyle advice delivered in the DPP?

• 16-lesson curriculum covering diet, exercise and behavior modification • curriculum taught by case managers on a one-to-one basis during first 24 weeks • curriculum followed by monthly individual sessions and group sessions designed to reinforce behaviour changes • sessions flexible, culturally sensitive and individualised • case manger • cost to deliver the intervention in the first year was $US1,399 per participant How was the lifestyle advice delivered in the DPS?

• Individually designed programme taking into account needs, interests, educational level and person who is ‘primarily in charge of preparing food at home’ • Baseline 3-day food record to form basis of dietary advice • Advise CHO – 50%; saturated fat <10%; mono- and poly-unsaturated fat 20-25% protein approx 1.0g protein per kg ideal BW per day dietary fibre – 15g per 1000kcal, if tolerated • Visits at baseline, 1-2 weeks, 5-6 weeks, then 3, 4 and 6 months, then 3-monthly • If no weight loss at 6-12 months and BMI >30kg/m2, then 6-12 week VLCD and group meetings at 1-2 weekly intervals Supplement— Education in Training Medical and Other Health Care Professionals

“Nutrition and physical activity are key risk factors for a host of today’s most prevalent and costly chronic conditions, such as obesity and diabetes; yet, health care providers are not adequately trained to educate patients on the components of a healthy lifestyle.”

Levy MD, Loy L, Zatz LY. Policy approach to nutrition and physical activity education in health care professional training. Am J Clin Nutr 2014; 99(suppl):1194S-201S. HOW? Prediabetes intervention package (PIP) in primary care study Prediabetes intervention package (PIP) in primary care study

To examine the effect and implementation of a multilevel primary care nurse-led prediabetes lifestyle intervention compared with current practice on weight and glycated haemoglobin in patients with prediabetes at 6 months. Approach to nutritional advice

Lipids, Blood pressure, Glycaemic control

Cultural background Lifestyle

Family & Employment Budget Lifestyle questions Weight History

• Special Diet or food allergies (tick if • Has your weight tended to go up and applicable): Vegetarian, Vegan, down? Pescatarian (vegetarian + fish), Nut • How long have you been your current free, Dairy free, Gluten free , Etc weight? • Physical activity – frequency and type Clinical Notes – suggested optional questions • Please indicate who you live with? • What was a weight that you felt • Who mostly buys food in your house? comfortable at? • Who mostly cooks food in your house? • Where do you hope to be in 6 Months?

• Is your budget for food limited? On a • Where do you hope to be in 2 Years? scale of 1 - 10, how ready are you to Diet Assessment make food changes (1 - not ready at all; 10 – really motivated)? • Starting The Conversation (STC): Diet • Detailed Dietary Assessment Guide

Goals - examples

• Less margarine on toast/bread. Just a scraping. Half the amount of butter in mashed potatoes

• Plan in advance cooking extra meals in days off

• To watch how much fruit is used in smoothies

• Will swap takeaway fast foods once per week i.e. stuffed fried chicken dish to either small chicken chow mein or turkish wrap with hummus

• change from coke to diet sodas - add a glass of water a day in the morning and decrease from 3 to 2 teaspoons of milo

One participant’s story

• 61 year old Pacific woman. Lived by herself. No local family support. • Both mum and dad history of Type 2 DM. • Did no exercise. • Weight had been constant for 18 months. • Food budget was $20 per week. • Attended churches for food. • Used Food banks. Baseline Measures

• HbA1c: 46 mmol/mol • Weight: 125.7 kg • Waist : 134 cm • BP: 136/84 mmHg • BMI: 47.6 kg/m2 Dietary Information

Main diet intake: • Bag Powdered milk • Bag Rolled oats • Potatoes • Noodles • Occasionally $5.00 pork bones • $1 bread • Limited meat • Limited vegetables • $2.00 bag biscuits 3-month follow up

Baseline 3 month

HbA1c 46 mmol/mol 44 mmol/mol

Waist 134 cm 112 cm (22 cm loss)

Weight 125.7 kg 124.4 kg (1.3 kg loss)

Blood pressure 136/84 mmHg 132/82 mmHg Another participant’s story

• 53 year old Maori man with partner living in another town. • Unemployed. • Current smoker. • Ischemic heart disease, COPD. • Prediabetes diagnosed 2014 (HbA1c 42 mmol/mol) • CVRA >20% • Medications - Flixotide, Duolin, Aspirin, Dilitazan Hydrochloride, Atorvostatin, Nitrolingual spray. Baseline Appointment

• HbA1c: XX mmol/mol Nutritional goals • Weight: 86.5 kg 1. Increase fruit to 2 servings daily. • Waist circumference: 98 cm 2. Increase veges to 4 servings • BP: 159/104 mmHg daily. • Weight loss goal 8.65kg 3. Reduce usual sugar in coffee by half to 2 tsp each cup.

• Financial Stress. • Non compliant with meds - GP appt. 2-3 week Appointment – attended with partner

• Weight increased by 2.5 kg Revised nutritional goals • BP: 159/110 mmHg • New goal - source apples, bananas and mandarins. Eat 2x daily. • Eating veges 3x daily • Discussed Kia Ora community • Reduced sugar in coffee to 2 tsp education programme. per cup • Appt made GP - WINZ and Kiwisaver. • Decreased salt intake & eating fish • Referred to Social Worker. 2x week • Refused smoking cessation support. 6 week Appointment

• Achieved previous nutrition goals Revised nutritional goals

• Weight decreased to 83.5 kg • Plan and prepare healthy snack • Waist circumference decreased to options. 94 cm [4cm less than at baseline] • Eat chips 1x week. • BP 140/101 mmHg • Referred to Kia Ora programme. • Waiting to hear back from Social Worker. Month Weight BMI HbA1c Goal 1 Goal 2 Goal 3

0 79.7 29.45 44 healthy takeaways, ie healthier sweet increase vege portions subway or turkish options ie smoothie, and decrease plate fruit, size 1 77.9

3 73.5 27.16 41

6 70.3 25.98 40

Had takeaway last week, had turkish. Denied self ice cream at the movies, is being minndful when openns fridge not to pick, having smaller meat portions. 3rd PIPI visit - pt done so well, great wt loss\bp 158/80\wt 73.5\wc 92.5Has passed wt goal which was 76kgwc originally 100cm. …..been very focussed on her weight and food goals and is a bit concerned as has been staying with her daughter to help out and they eat higher fat and CHO than she likes. I can see that she prefers to eat her healthy options with the occasional sweet treat. Pt has been grateful for this opportunity. Month Weight BMI HbA1c Goal 1 Goal 2 Goal 3

0 82.7 27.63 41 To increase non-starchy To reduce amount of Stop having desserts vegetables to 7+ serves crackers per week to 2-3 and fill half the meal times, alternate cheese plate with vegetables with cottage cheese 1 81.1 41

3 78.4 26.2 43

6 77.0 25.73 40

Is achieving all goals and would like to continue with these as he feels they are working really well. He found the first 2/7 difficult but felt that it was a habit he could break. He has lost 1.6 kg. Green rx referral faxed. Doing well lost more weight, happy with goal, achieving these nicely.looking forward to knowing what effect this may have made on his bloods Has achieved all goals and will continue to do this. Found the green rx modules of benefit particularly the label reading, enjoyed the modules! Has lost nearly 6kg. His weight goal was 78 so achieved this. Feels happy at the weight he is now and would like to maintain this rather than lose more. Keen to follow up in 2-3mths for weight and nutrition r/v. Recall set. Other personal and ‘life’ considerations

• Diet modification challenges faced by marginalized and nonmarginalized adults Self- with type 2 diabetes: A systematic review discipline and qualitative meta-synthesis. [Vanstone M, Rewegan A, Brundisini F, et al. Chronic Illn. 2017;13(3):217-235.] Knowledge Family and • Five inter-connected barriers to and social diet modification that are support magnified by social information Dietary marginalization. change • Abel S, Whitehead LC, Coppell KJ. Making dietary changes following a diagnosis of prediabetes: a qualitative exploration of barriers and faciliators. Social Diabet Med. 2018 Aug 9. doi: Emotions significance 10.1111/dme.13796. [Epub ahead of print] of food “Can look at a habit now and decide if I want to keep it or change it.” Collaborators

Trish Freer, Health Hawke’s Bay Leigh Perreault, University of Colarado Kiri Sharp, University of Otago David Tipene-Leach, Eastern Institute of Technology Joanna Norton, University of Otago Tony Merriman, University of Otago Sally Abel, Kaupapa Limited Jeremy Krebs, University of Otago Terry Spedding, Health Hawke’s Bay Angeline Tangiora, Health Hawke’s Bay Rachael Engelbrecht, Tamatea Medical Centre Diane Stride, Diane Stride Postgrad Students Lillian Ward, Health Hawkes’ Bay Deborah Connor, University of Otago Andrew Gray, University of Otago Lisa Whitehead, Edith Cowan University, Australia Research Assistant Trudy Sullivan, University of Otago Courtney Mizen, Edith Cowan University, Australia Acknowledgements

Practice nurses from Greendale Family Health Centre The Doctors Napier Te Mata Peak Practice Clive Medical Centre The Hastings Health Centre Hauora Heretaunga Medical and Injury Centre Maraenui Medical Centre Tamatea Medical Centre Chris Peterson & Helen Morris Faye Milner & Janet Hill Diabetes New Zealand Healthy Food Guide Zoe McCulloch Southern Community Laboratories Lenore Armstrong & Leslie Turner

The pre-diabetes tidal wave - harbinger of doom or symptom of an overdiagnosis epidemic? NIKKI MACDONALD April 15 2017

…..diagnosed with pre-diabetes about three years ago, after having an Hba1c test’…never considered herself at risk of diabetes….”I thought I was far too active for that.“ She knew diabetics, who needed insulin injections, and her fear of needles was motivation enough to change. She was referred to the Otago University pilot Pre-diabetes Intervention Programme in Primary Care (Pipi), trialling targeted diet advice through GP practice nurses…….She now eats fewer strawberries and greener fruit…swapped white rice for couscous or mixed rice, eats more fish and only fibre-dense bread. When family visit, it's a big feed, but a healthy one. "They know what I'm doing and that I won't allow them to have rubbish. Napier 70-year-old Gayle Peters was told she Not here." She's lost some weight, and has not progressed to full diabetes. was pre-diabetic about three years ago. With Overall, she found the experience "very useful“…….As you do it more and it targeted diet advice, she reduced her sugar and carbohydrate intake and has not progressed to starts becoming more second nature, it's just changing your style of living." diabetes. PHOTO: SUPPLIED http://www.stuff.co.nz/national/health/90768856/The-pre-diabetes-tidal-wave-harbinger-of-doom-or-symptom-of-an-overdiagnosis-epidemic Prevalence of obesity (BMI ≥30 kg/m2) among New Zealand men and women aged 15+ years

Women Men 40

35

30

25

20

15 Proportion Proportion (%)

10

5

0

Year

Ministry of Health. 2013. New Zealand Health Survey: Annual update of key findings 2012/13. Wellington: Ministry of Health. Ministry of Health. 2017. New Zealand Health Survey. Annual Data Explorer. minhealthnz.shinyapps.io/nz-health-survey-2016-17-annual-data- explorer/_w_ba211a39/#!/home