Dietary Interventions – Clinical Case Adults

Mary O’Kane FBDA Consultant in Adult Leeds Teaching Hospitals NHS Trust Case study - Maria

34 year old woman 157 kg – BMI 54.4 kg/m2

World obesity image bank In your initial consultation, what would you like to know about her? Dietary interventions: Dietetic assessment

Weight history and history Expectations/goals Current eating pattern – regular , snacks, consumption of drinks including alcohol, quality of – Types of food eaten, whether she cooks, ability to cook, dentition “Typical day” Disordered eating – binge eating, bulimia Psychosocial – Support networks – Barriers to change – Willingness to engage Mental health Nutritional assessment – Ferritin, folic acid, B12, , HbA1c Case study - Maria

34 year old woman 157 kg – BMI 54.4 kg/m2 Intracranial hypertension, cardiovascular hypertension, no history of depression, non- smoker, rarely has alcohol Lives with 2 children, 7 year old and 12 year old Used to work as care assistant but injury at work, damaged left hip and persistent bursitis Now at heaviest weight. Has tried various diets, most lost is 6kg, gets disheartened and then regains Maria – nutritional assessment

Nutritional status – screen for vitamin D, folate, ferritin, vitamin B12 Binge eating? – Reports that never binges “Typical Day” – how does food fit in to the day? Typical day – Wakes up, takes tablets with water at 6.30 am. Followed by slice of toast – Takes children to school, comes home, tidies up – 1pm – if hungry – “picks” or tinned soup or nothing – Picks up children from school – Evening – pork chop and carrots, grilled steak and carrots, Chinese pork and noodles – Drinks coke over the day Views on diet? Diet history – what influences what we report?

Evidence that we all under-report what we eat and over-report our activity Memory –”eating on the go”, eating unconsciously Portion sizes increased Fear of being judged, stigma, weight bias What might you learn from typical day? – Insight into lifestyle and where food fits in – Knowledge, understanding, beliefs – Potential enablers, potential barriers What would you discuss with her – remember it’s the initial assessment Followup

6 weeks later – 155 kg – Nutritional status – vitamin D (low), folate (low), ferritin (low), vitamin B12 (normal) – Kept food diary for week before appointment – Toast for breakfast and Slimfast for lunch and cooked evening meal. May miss meals, has snacks and drinks Lucozade (Used to have Toast, 1pm – if hungry – “picks” or tinned soup or nothing, Evening meal – pork chop and carrots, grilled steak and carrots, Chinese pork and noodles) – Wants to go forward for bariatric surgery – What would you discuss? Followup

6 weeks later 155 kg Nutritional status – screen for vitamin D (low), folate (low), ferritin (low), vitamin B12 (normal) Vitamin D, folic acid and iron replacement – and dietary sources Kept food diary for week before appointment – Toast for breakfast and Slimfast for lunch and cooked evening meal. – May miss meals, has snacks and drinks Lucozade for energy – Ask the patient if she would like to discuss food dairy and whether she wants feedback. Discuss objectively. Wants to go forward for bariatric surgery – Started to discuss what surgery means, impact on diet, behavioural changes required, directed to patient support group Open questions and listening

Dietitian. How have the last few weeks been? – Patient - Hard – my son has learning difficulties and dislikes his new school so it is difficult to get ready in the morning – Dietitian – that must be difficult. I see that despite that, you have managed to have breakfast every morning. How has that been? Dietitian – take me through the rest of the day – Patient – I tried to start eating at lunch time but with the morning being so stressful, I found it easier to have Slimfast – Dietitian – it’s good that you are having lunch more regularly. How do you find the Slimfast? Dietitian – I’ve noticed that you have missed a few meals. What are the reasons for that? – Patient – the evening meal can be stressful as my children are tired and argue so I avoid eating at the same time. I have some Lucozade to keep me going. Later, I cannot be bothered to eat so I grab a bag of crisps or a bar of chocolate. Next steps

Dietitian – It’s great that you are managing breakfast and having lunch regularly. How hard has that been to do? – Patient –having a Slimfast means that I don’t need to think about what I am doing and it’s portion controlled Dietitian - It sounds like evening meal time is stressful – and that results in you missing a meal and then having a sugary drink and snack. – Patient – yes, it is stressful but the Lucozade gives me energy and and I’m not snacking as much Losing weight is important to you. Would you like any feedback about your food intake? Any suggestions about how to move forward? – Information about sugary drinks – Overall quality of – Links between missing meals and loss of control with food intake Dietitian – offer choices, what works for others Followup

12 weeks later – 150 kg. – Hospital admission with infections – discharged on supplement drinks 18 weeks later – 148 kg – encouraging to return to food 24 weeks later – 144kg Urinary tract infection and tonsillitis. Further hospital admission Missed appointment 36 weeks later – 149.7kg – Reports small meals and Slimfast drinks – What’s your initial thoughts? January 2019

Dietitian – how have the last few weeks been? Patient – Weight had increased to 150.8 kg but now 146.5kg – Now joined Slimming World – Introducing more fruit and vegetables – Stopped Red Bull drinks and other sugary fizzy drinks – Daughter –eating disorder – Not certain about bariatric surgery because of all the infections March 133.5 May 129 kg Which diet to try? 45% of registry lost an participants average of lost the weight 66 lbs and on their own kept it off and the other for 5.5 years 55% lost weight with the help of ranged from 30 some type of to 300 lbs program

98% of Registry Duration of participants successful report that they has modified their ranged from 1 food intake in year to 66 years some way to lose weight Current self-regulation and self-monitoring strategies used to maintain or lose weight (National Weight Control Registry) Ogden et al 2012 Professional and group resources used during successful weight loss (NWCR) Ogden et al 2012 Eating patterns/behaviours - NWCR

Self-monitoring weight on a regular basis - 75% weigh themselves at least once a week. Maintaining a consistent eating pattern – 78% eat breakfast every day – Shopping with a list /Planning – Not shopping when hungry – Food diary – Avoiding fast foods Catching slips before they turn into larger regains Weight maintenance

Equal importance to the weight loss phase Uses different skills to the weight loss phase Post-treatment contact aids weight maintenance (weight monitoring, physical activity) Commercial slimming groups can help play a role in this

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Training for health care professionals? Dietetic input? Stepped food reintroduction (2– 8 weeks), and structured support for long-term weight loss maintenance? Does the patient pay for the product? For those unable to adhere to the programme or who do not get the results, what next? Intermittent diet – Dr Michelle Harvie RD

Dr Michelle Harvie – research into impact of Intermittent

fasting on breast cancer prevention But number of books for sale is now greater than the number of participants in the research study! Intermittent energy restriction (IER)/ for weight management in adults (Harvie 2017)

IER can be as effective as standard daily Continuous Energy Restriction for weight loss in adult patients with and without type 2 diabetes (limited number of RCTs) IER -incomplete energy intake compensation if healthy eating is advised on non-diet days IER diets should provide dietary guidance on the types and amounts of food to consume on restricted days. Restricted days - minimum of 50g protein and 50g carbs Further research needed Low carbohydrate (CHO) diets

• Low CHO diet <130g/day • Low CHO ketogenic diet <50g/day The DIETFITS Randomized Clinical Trial (Gardner et al 2018 JAMA. 2018;319(7):667-679. doi:10.1001/jama.2018.0245 )

Effect of a healthy low-fat (HLF) diet vs a healthy low-carbohydrate (HLC) diet – on weight change at 12 months related to genotype pattern or insulin secretion? 1st 8 weeks: – HLF group – 20g fat/day – HLC group -20 g CHO/day Gradually increased amounts to level they thought they could maintain Not advised to cut calories – HLF diet 29% fat, 48% CHO – HLC diet 45% fat, 30% CHO The DIETFITS Randomized Clinical Trial (Gardner et al 2018 JAMA. 2018;319(7):667-679. doi:10.1001/jama.2018.0245 )

12-month weight loss diet study: no significant difference in weight change between a HLF (5.3 kg) vs HLC (6kg) Both groups cut calories by approximately 500 to 600 kcal/day neither genotype pattern nor baseline insulin secretion was associated with the dietary effects on weight loss neither of the 2 hypothesized predisposing factors was helpful in identifying which diet was better for whom