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 weight loss 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 meal replacement diet 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 obesity 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 prediabetes 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. Number 6000 4000 8000 2000 5000 3000 1000 7000 Annual number of publications on loss, on weight of publications numberAnnual 0 1859 1908 1914 1918 1925 1928 1932 1935 1938 1942 1945 1948 1951 1954 1957 Year 1960 1963 1966 1969 1972 1975 1978 1981 1984 1987 1990 1993 1859 1996 1999 2002 - 2018 2018 2005 2008 2011 2014 2017 List of ‘fad’ diets • The 4-Hour Body • Macrobiotics • Whole30 diet • 5:2 diet • Master Cleanse • High carb/low fat diets • Dr. Dean Ornish: Eat More, Weigh • Alkaline diet • [Mediterranean diet] Less • • Baby Food Diet] • Morning banana diet The Good Carbohydrate Revolution • the Pritikin Principle • Blood type diet • Paleolithic diet • Food combining • Cabbage soup diet • Pritikin Diet • Fit for Life • Detox diet • Scarsdale medical diet • Suzanne Somers’ Somersizing • Dukan Diet Fruitarianism • South Beach Diet • Liquid diets • Cambridge Diet • Gluten fee diet, while essential for • Superfood diet people with coeliac disease or gluten • Slim-Fast sensitivity, has also been a fad. • Veganism • Diet pills, supplements and herbal • Grapefruit diet • Ketogenic diet remedies • Dexatrim Natural • Israeli Army diet • Low-carbohydrate diets • HCG diet • Atkins diet • Juice fasting • Hydroxycut • Sugar Busters • Metabolife 356 • KE diet • Zone 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—Nutrition 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.