Healthy Eating and Weight Management Diabetes Dietitians Agenda
Healthy Eating and Weight Management Diabetes Dietitians
Agenda • Evidence based nutritional guidelines in diabetes • Weight management and current guidelines on management • Di. RECT • Healthy eating • Case study • Low carb diets • Bariatric surgery • When to refer to dietitian
How to Lose Weight What guidance would you give to your patients at present? • Advice is based on guidance from Diabetes UK, BDA Obesity Specialist Group and NICE • NICE CG 189 Obesity (Nov 2014) – Dietary changes should be individualised, tailored to food preferences and allow for flexible approaches to reducing calorie intake – Unduly restrictive and nutritionally unbalanced diets should not be used, because they are ineffective in the long term and can be harmful
Evidence Based Guidance Evidence-based nutrition guidelines for the prevention and management of diabetes (Diabetes UK) • Updated March 2018 • Focuses on food based guidelines in line with US and Brazil • Acknowledges relevance of foods and overall eating patterns for improved health outcomes • Tailors advice to the individual (taking into account culture and personal preference)
Weight Management and Remission of T 2 DM • Aiming for weight reduction of approx 15 kg as soon as possible after diagnosis can achieve remission • Remission of T 2 DM can be achieved in: – 11% of people who achieve 8% weight loss – 73% of people who lose >10 kg weight – 86% of people who lose >15 kg weight • >5% weight loss significantly improves Hb. A 1 c, cholesterol (total, LDL and HDL), TGs, BP and insulin sensitivity
Weight Management and Remission of T 2 DM • Uncertainty remains on the most effective dietary intervention for weight loss • Evidence suggests degree of adherence is more important than the dietary strategy • Exercise alone may not be effective for weight loss in T 2 DM unless 60 mins daily but still has many health benefits (glycaemic control, CV risk and wellbeing) • VLEDs give greater weight loss at 3 -6 months (not NICE recommended and for no longer than 12 weeks continuously or intermittently as part of other weight management strategies) • TDR (800 -1200 kcals daily) for 12 weeks induce weight loss of 15 kg and remission of T 2 DM
Glycaemic control and T 2 DM • Total amount of carbohydrate consumed is a strong predictor of glycaemic response • Unclear what ideal macronutrient proportions recommended for optimal glycaemic control • Total energy intake and weight loss are significant factors • Low GI diets may reduce Hb. A 1 C by 4 -6 mmol/mol (0. 5%)
Di. RECT • Intensive low-calorie, diet-based, weight management programme • Recruited 306 participants for the study, all from GP practices across Scotland Tyneside • Diagnosed with Type 2 diabetes within six years of starting the study. • low-calorie diet of 800 calories a day is made up of four soups or shakes for 8 -20 weeks. • Gradually reintroduce normal food and get expert support to help them maintain their weight loss in the long term. • 24 month data showed sustained remission for over a third of people with type 2 diabetes with weight loss of ≥ 10 kg.
NICE Guidance • Diets that have a 600 kcal/day deficit or that reduce calories by lowering the fat content in combination with expert support and intensive follow-up, are recommended for sustainable weight loss • Low-calorie diets (800– 1600 kcal/day) may also be considered, but are less likely to be nutritionally complete • Do not routinely use very low calorie diets (800 kcals/day or less) to manage obesity (BMI over 30)
The BDA Obesity Specialist Group – Guidance (2018) The 600 kcal deficit approach • The 600 kcal deficit approach has been demonstrated to be an effective strategy • A review of 13 randomised controlled trials showed a weight loss of -5. 32 kg compared with usual care at 12 months • These diets are in line with the dietary recommendations for good health Dietetic Obesity Management Interventions in Adults: Evidence Review and Clinical Application – The BDA Obesity Specialist Group, January 2018.
Healthy Eating “Helping patients begin to move towards the general recommendations for a healthier diet, even if weight change is limited, is important in establishing eating habits known to be associated with many health benefits” (BDA Obesity Specialist Group, 2018)
Weight Management – Dieting
Available Diets • Healthy eating with 600 kcal deficit • Prescriptive diets – 1200, 1500 and 1800 kcal diets, Tesco diet • Slimming World / Weight Watchers • Slimfast / meal replacements • 5: 2 Diet • Very low calorie diets • Bariatric surgery
What can you achieve? First line treatment: • • • Healthy (balanced) eating approach Regular meals Reduce snacking Calorie deficit Direct to weight management groups / exercise programs within your area
Putting this into Practice Energy balance
How can we achieve a 600 kcal deficit?
Portion Sizes for Weight Loss This meal contains 676 kcal This meal contains 476 kcal Overall saving = 200 kcal
Low Fat This meal contains 476 kcal This meal contains 358 kcal Overall saving = 118 kcal
Snacking • Choosing healthier snacks can help reduce calories. Chocolate muffin 353 kcal 2 Chocolate biscuits 258 kcal Half a chocolate bar – 130 kcal ¼ sharing bag of crisps – 192 kcal + Fruit loaf 130 kcal Saving 223 Kcal 2 Rich tea 62 kcal Saving 196 Kcal Apple 46 kcal + 5 kcal Saving 79 Kcal 25 g pack of low fat crisps – 109 kcal Saving 83 Kcal
Alcohol 35 ml gin and slimline tonic = 72 kcal 175 ml glass white wine = 130 kcal Pint of lager = 220 kcal
Increasing Activity Calories used (per hour) for an 82 kg person Calories used (per hour) for an 120 kg person Walking 3. 5 miles/hour 353 516 Aerobics class 598 876 Swimming 394 576 Exercise bike (moderate) 557 816
Case Study Mrs L • T 2 DM diagnosed March 2014, high BMI (44) weight 114 kg Hb. A 1 c (Nov 2014) 48 mmol/mol • Treated with Metformin and prescribed Orlistat (not taking) • Breathless upon activity therefore limited exercise
Diet History • Breakfast Skips 4/7 or full bowl porridge with semi-skimmed milk at 10 am/10. 30 am • Lunch (2 pm) Sandwich – brown and thick cut (2 slices) with butter with ham and cheese filling No puddings • Evening meal (6 -7 pm) Spag bol or potatoes, steak/fish Veg 5/7 Portions – carb and protein heavy, small amount veg and has large square plates No puddings • Snacks Fruit – large quantities in one sitting twice daily eg) full punnet of raspberries or large banana or picks on bag of grapes (often eating half bag) What changes would you make to Mrs L’s diet?
What changes could be made? • Focus on meal regularity – Regular metabolism – Weight loss more successful with inclusion of breakfast • Fruit portions – Aim for max 3 portions daily (140 kcal saving) – 1 portion fits in palm of hand except dried fruit or fruit juices – Although healthy alternative, extra carb = extra kcals. Set times for snacks. • Meal portions – Breakfast cut down porridge to half bowl (0 -200 kcal saving) – Lunch use medium cut granary bread or roll (60 kcal saving) , add salad (half plate), use ham or fish over cheese (200 kcal saving) and low fat spread or olive based spread (30 kcal saving) – Evening meal aim for ½ plate veg/salad, ¼ plate CHO and ¼ protein; veg/salad daily; low GI choices (pasta/basmati rice/sweet potato); smaller plates (standard plate) (est 100200 kcal saving) TOTAL CALORIE DEFICIT – 530 – 830 Kcal/day.
Set Small Achievable Goals • Work collaboratively with patient • What do they want to work on first • Set 1 – 3 goals depending on patient • Gradually make changes, set new goals at review appts if achieving goals • Use SMART goals to help with this
Low Carb Diets • Low-carbohydrate diets (vary between 50 g and 130 g carbohydrate) can be effective in managing weight, improving glycaemic control and cardiovascular risk in people with Type 2 diabetes in the short term – 3 -6 months (Diabetes UK 2018). • More research is needed to understand the long-term health impacts of a low-carbohydrate diets, including on heart health • When people restrict their intake of carbohydrate, the relative amounts of other macronutrients (fat and protein) tend to increase. • When considering a low carbohydrate diet as an option, people with diabetes who are on certain drugs including insulin or Gliclazide should be made aware of possible side effects such as the risk of hypoglycaemia or in rare cases ketoacidosis
Tier 3 Weight Management Service • Referrals from GPs in Vo. Y CCG for pts BMI 35 and above • Pts interested in bariatric surgery must be referred into this service prior to consideration for surgery • MDT consists of Consultant Endocrinologist, Physio, Dietitian and Counsellor
Bariatric Surgery in T 2 DM What is new? Current NICE guidelines (2014) suggest: • Consideration for surgery in recent onset T 2 DM with BMI 30 and above and under level 3 care • Locally, patients remain eligible for surgery with BMI 35 and above with co-morbidities providing they have been through weight management programme NICE Clinical Guideline CG 189 (Nov 2014) Obesity: Identification, Assessment and Management
When to Refer to the Dietitian Detailed dietary assessment needed Behavioural change approach Prescriptive diets Intensification of treatment led to weight gain Consideration for Orlistat (Xenical) or bariatric surgery • Obesity and commencement of insulin considered. • • •
Summary • Stabilise eating patterns • Healthy eating approach • Work on achieving calorie deficit
Any Questions?
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