A review of one-to-one dietetic obesity management in adults

Exploring the highs and lows of very low carbohydrate high fat diets on weight loss and diabetes- and cardiovascular disease-related risk markers: A systematic review

AIM

Very low carbohydrate high fat diets (VLCHF) are increasingly popular for weight loss and diabetes management, but the risk implications of long-term adherence to a high-fat-diet remain unclear, especially in high-risk populations. This review aimed to examine adherence, weight loss, diabetes- and cardiovascular disease (CVD)-related risk markers in adults consuming VLCHF diets.

METHODS

Online databases were searched for randomised controlled trials ≥3 months duration that met a pre-defined macronutrient prescription: VLCHF ≤25%E carbohydrate, >35%E fat; low fat (LF) ≥45%E carbohydrate, ≤30%E fat; and reported energy, saturated fat (SFA), weight, blood glucose, cholesterol and blood pressure (BP). Studies were excluded if the macronutrient prescription was not targeted (n = 32); not met (n = 17) or not reported (n = 13).

RESULTS

Eight studies included: 1217 commenced; 922 completed overweight and obese adults. Diets were isocaloric moderately energy-restricted, closely monitored with ongoing support from dietitians, physicians, and/or nurses. Four studies reported non-adherence beyond 3 months (n = 3) and 6 months (n = 1) despite interventions of 12, 15 and 24 months. VLCHF diets were high in fat and SFA (fat 49%-56%E; SFA 11%-21%E) compared to LF diets (fat 13%-29%E; SFA 5%-11%E). All groups achieved significant weight loss and improvements in BP and blood glucose. LDL-C reduction favoured LF, P < .05; increased HDL-C and reduced triglyceride levels favoured VLCHF, P < .05.

CONCLUSIONS

VLCHF and LF diets with moderate energy restriction demonstrate similar weight loss and improvements to BP to 3 months. However, adherence is likely poor without intensive support from health professionals. Dietary SFA should be monitored to ensure recommended intakes, but longer-term studies with high adherence are required to confirm the level of CVD-risk and potential harms.

Emotional overeating questionnaire: a validation study in Italian adults with obesity, overweight or normal weight

PURPOSE

This study aimed at testing the validity and reliability of the Emotional Overeating Questionnaire (EOQ) in a sample of Italian adults with obesity, overweight or normal weight.

MATERIALS AND METHODS

Participants were 314 Italian adults (72.6% females, aged 18-76 years) with obesity (27.4%), overweight (21.3%), or normal weight (51.3%), who completed the EOQ and measures of binge eating, mental well-being, and mindful eating. Retesting was performed 4 weeks later in a randomly selected subsample of 60 participants. Factor structure of the EOQ was estimated by confirmatory factor analysis (CFA). Reliability was tested with McDonald's ω and ordinal α coefficients for internal consistency and Cohen's weighted Kappa coefficient (K_w) for test-retest reliability.

RESULTS

Based on CFA, the five negative emotional items formed one factor (EOQ-5) with good reliability (ω = 0.89; ordinal α = 0.88; K_w= 0.71), while the item referring to happiness was dropped. EOQ-5 scores were associated with higher binge eating, lower mental well-being, and lower mindful eating. A cut-off point of two identified individuals at risk for binge eating disorders with 75% sensitivity and 67% specificity. Negative emotional overeating was more frequent in women with obesity than women with normal weight and men with obesity.

CONCLUSIONS

EOQ-5 is a valid and reliable tool for measuring the frequency of emotional overeating at the Italian community-level.

LEVEL OF EVIDENCE

Level V, cross-sectional, descriptive study.

Low-energy total diet replacement intervention in patients with type 2 diabetes mellitus and obesity treated with insulin: a randomized trial

OBJECTIVES

The management of patients with long-standing type 2 diabetes and obesity receiving insulin therapy (IT) is a substantial clinical challenge. Our objective was to examine the effect of a low-energy total diet replacement (TDR) intervention versus standardized dietetic care in patients with long-standing type 2 diabetes and obesity receiving IT.

RESEARCH DESIGN AND METHODS

In a prospective randomized controlled trial, 90 participants with type 2 diabetes and obesity receiving IT were assigned to either a low-energy TDR (intervention) or standardized dietetic care (control) in an outpatient setting. The primary outcome was weight loss at 12 months with secondary outcomes including glycemic control, insulin burden and quality of life (QoL).

RESULTS

Mean weight loss at 12 months was 9.8 kg (SD 4.9) in the intervention and 5.6 kg (SD 6.1) in the control group (adjusted mean difference -4.3 kg, 95% CI -6.3 to 2.3, p<0.001). IT was discontinued in 39.4% of the intervention group compared with 5.6% of the control group among completers. Insulin requirements fell by 47.3 units (SD 36.4) in the intervention compared with 33.3 units (SD 52.9) in the control (-18.6 units, 95% CI -29.2 to -7.9, p=0.001). Glycated Hemoglobin (HbA1c) fell significantly in the intervention group (4.7 mmol/mol; p=0.02). QoL improved in the intervention group of 11.1 points (SD 21.8) compared with 0.71 points (SD 19.4) in the control (8.6 points, 95% CI 2.0 to 15.2, p=0.01).

CONCLUSIONS

Patients with advanced type 2 diabetes and obesity receiving IT achieved greater weight loss using a TDR intervention while also reducing or stopping IT and improving glycemic control and QoL. The TDR approach is a safe treatment option in this challenging patient group but requires maintenance support for long-term success.

TRIAL REGISTRATION NUMBER

ISRCTN21335883.

The Role of Diet in Patients with Metabolic Syndrome

Metabolic syndrome is a frequent metabolic disorder characterized by obesity and insulin resistance seems to be the main pathophysiological alteration. The goal of treating metabolic syndrome is to reduce the risk of coronary heart disease and the development of type 2 diabetes. The lifestyle modification therapy combines specific recommendations on diet alone or combined with other strategies. In this review, we address the following topics: 1) the importance of the high prevalence of metabolic syndrome and obesity, and 2) the role of lifestyle modification focusing on dietary fat intake in the management of MS.

Facilitators and barriers to a dietitian-implemented blended care weight-loss intervention (SMARTsize): a qualitative study

BACKGROUND

Dietitians play an important role in the intervention and prevention of being overweight and obesity. More and more blended care interventions are being implemented. The present study aimed to evaluate the delivery by Dutch dietitians of a multicomponent, evidence-based weight-loss programme (SMARTsize), including counselling for relapse prevention. The aim of this qualitative study was to identify facilitators and barriers to the delivery of SMARTsize.

METHODS

Nine semi-structured interviews were conducted with 10 dietitians who participated in a larger implementation study. Each interview was recorded and transcribed verbatim. Determinants of theory of implementation, including characteristics of the user, the innovation, organisational context and setting, and innovation strategy guided interviews and analysis. Data were coded and analysed using the framework approach.

RESULTS

According to dietitians, the SMARTsize intervention had a positive influence on patients. The main implementation facilitators were the availability of implementation materials, such as a manual, training in relapse prevention and social support from other dietitians. The main barriers to implementation were organisation and financial reimbursement of cooking classes, the belief that patients need more individual counselling in the starting phase, and the unsuitability for people with low levels of health literacy.

CONCLUSIONS

Most dietitians considered that implementation of the SMARTsize intervention consisting of e-health, written information and cooking classes and face-to-face counselling is challenging but feasible. Further development of the SMARTsize intervention and implementation tools is needed to lower experienced barriers. It is also recommended that a version of the intervention to be developed that is suitable for patients with lower levels of health literacy.

Australian dietitians' beliefs and attitudes towards weight loss counselling and health at every size counselling for larger-bodied clients

AIM

Research suggests that dietitians now employ weight-neutral (WN) approaches (Health at Every Size (HAES), Intuitive Eating and non-diet) as well as more traditional weight-centric (WC) approaches (weight loss counselling) to address adult weight concerns. This study aimed to compare the knowledge of and attitudes towards WN practice compared with WC practice in Australian dietitians who work with larger-bodied clients as delineated by practice approach.

METHODS

A cross-sectional web-based knowledge, attitudes and practices survey was conducted with Australian dietitians who counsel adults with a body mass index >25 kg/m² . Based on their responses, dietitians were categorised into WC (preferring weight loss counselling), WN (preferring HAES counselling) or mixed approach (MA). Between-group comparisons were conducted using Pearson's chi^- squared tests for knowledge and practice and independent t-tests for attitudes.

RESULTS

Of the 317 respondents, 18.3% fulfilled the criteria for WN practitioners, 30.3% for WC practitioners and the remainder were classified as providing a MA. Weight-neutral approaches were more positively regarded generally than WC approaches (84.5% vs 53.9%) as well as considered professionally responsible (86% vs 58.7%) and perceived as more helpful for clients (61.2% vs 35%). Knowledge of WN practice goals was poor with only 36.9% (n = 117) of the participants indicating correctly that this mode of treatment is incompatible with a weight loss goal.

CONCLUSIONS

Weight-neutral practice was considered acceptable by Australian dietetics professionals who counsel larger-bodied people regardless of their personal practice preference although many displayed inaccurate knowledge of WN approaches.

Mapping the contribution of Allied Health Professions to the wider public health workforce: a rapid review of evidence-based interventions

Objectives

The objective was to identify a selection of the best examples of the public health contributions by Allied Health Professionals (AHPs) in order to encourage a wider awareness and participation from that workforce to public health practice.

Study design

A mapping exercise was used to identify evidence-based interventions that could lead to health improvements across a population.

Methods

A rapid review was undertaken to identify evidence, followed by a survey of Allied Health Profession (AHP) practitioners and an expert panel consensus method to select the examples of AHP public health interventions.

Results

Nine evidence-based interventions are identified and selected as examples of current AHP good practice. These examples represent a contribution to public health and include screening interventions, secondary prevention and risk management.

Conclusions

This study contributes to a strategy for AHPs in public health by appraising the effectiveness and impact of some exemplar AHP practices that contribute to health improvement. There is a need for AHPs to measure the impact of their interventions and to demonstrate evidence of outcomes at population level.

Implementation of a Screening and Management of Overweight and Obesity Clinical Practice Guideline in an Ambulatory Care Setting

Introduction

Obesity is a rapidly growing health problem reaching epidemic levels around the world (World Health Organization, 2014). According to the World Health Organization, the current incident rate of obesity makes it the leading risk for deaths across the globe. The United States (USA) is amidst in this growing global epidemic. The obesity epidemic is a nondiscriminatory health problem affecting millions of individuals from a variety of backgrounds and social status. One group impacted by this disease is the US military. The health-related consequences of overweight and obesity has increased our military health care expenditures and has a direct impact on our nation's military readiness (Veterans Affairs/Department of Defense, 2014).

Materials and Methods

The purpose of this Doctor of Nursing Practice project was to implement the Veterans Affairs/Department of Defense's Clinical Practice Guideline on Screening and Management of Overweight and Obesity at a military treatment facility in the Midwest. The goal of the project was to reduce the incidence rate of overweight and obese active duty military service members assigned to a military installation in the Midwest. With institutional review board approval, project implementation results were analyzed with descriptive and inferential statistics (paired t- tests).

Results

The goal to reduce the incident rate of overweight and obese by 5% was not achieved, but in turn the rate of overweight and obese increased by 1.57% over the 6-mo period. There were decreases in the normal with an increase in the overweight and obesity rate. This inverse outcome was unexpected and concerning.

Conclusion

Based on the project's finding, there is a need to address the perceived barriers to maintaining healthy behaviors to plan future activities. An in-depth look at whether there is a knowledge deficit, a perceived lack of self-efficacy, competing life priorities preventing engagement in health promotion behaviors, or some other element influencing the motivation to change would be beneficial to understanding how to curb the growing rate of obesity. The utilization of the transtheoretical model of behavior change would make a sound theoretical framework to base such a new study, focusing on the stages of change as it relates to health promotion behaviors.

Developing dimensions for a multicomponent multidisciplinary approach to obesity management: a qualitative study

BACKGROUND

There have been consistent recommendations for multicomponent and multidisciplinary approaches for obesity management. However, there is no clear agreement on the components, disciplines or processes to be considered within such an approach. In this study, we explored multicomponent and multidisciplinary approaches through an examination of knowledge, skills, beliefs, and recommendations of stakeholders involved in obesity management. These stakeholders included researchers, practitioners, educators, and patients.

METHODS

We used qualitative action research methods, including convergent interviewing and observation, to assist the process of inquiry.

RESULTS

The consensus was that a multicomponent and multidisciplinary approach should be based on four central meta-components (patient, practitioner, process, and environmental factors), and specific components of these factors were identified. Psychologists, dieticians, exercise physiologists and general practitioners were nominated as key practitioners to be included.

CONCLUSIONS

A complex condition like obesity requires that multiple components be addressed, and that both patients and multiple disciplines are involved in developing solutions. Implementing cycles of continuous improvement to deal with complexity, instead of trying to control for it, offers an effective way to deal with complex, changing multisystem problems like obesity.

Weight management: A concept analysis

AIM

There is a need to develop sound healthcare practices where patients and providers are able to succeed in meeting weight management goals. The aim of this analysis is to develop a better understanding the concept of weight management.

BACKGROUND

Obesity is a rapidly growing healthcare issue, reaching epidemic levels around the world. According to the World Health Organization, the current incident rate of obesity makes it the leading risk for death across the globe.

DESIGN

Walker and Avant's model for concept analysis.

DATA SOURCE

A literature search was accomplished using Cumulative Index to Nursing and Allied Health, Health Source: Nursing Academic Edition, Medline, and ProQuest Health and Medical Complete.

REVIEW METHODS

Keywords included weight management, weight control, weight loss, obesity, weight, and management.

RESULTS

Weight management is complex concept. Strategies to develop successful weight management programs need to be multifaceted to have impact on this healthcare crisis.

CONCLUSION

The critical attributes for weight management are dietary measures, physical activity, behavior modification, motivation, education, and lifelong changes. Unsuccessful weight management results in metabolic disorders and increased risk of mortality. Successful weight management practices include the prevention of weight gain, weight loss, and maintenance of ideal body weight.

Outcomes of a community-based weight management programme for morbidly obese populations

BACKGROUND

Morbid obesity is an ongoing concern worldwide. There is a paucity of research reporting primary care outcomes focussed on complex and morbidly obese populations. The National Institute for Health and Care Excellence (NICE) recommends a specialist, multidisciplinary weight management team for the successful management of such populations. This is the first service evaluation reporting both primary (weight change) and secondary [body mass index (BMI), waist circumference, physical activity levels, fruit and vegetable intake, Rosenberg self-esteem score] outcomes in these patients.

METHODS

The present study comprised a prospective observational study of a cohort data set for patients (n = 288) attending their 3-month and 6-month (n = 115) assessment appointments at a specialist community weight management programme.

RESULTS

Patients had a mean (SD) initial BMI of 45.5 (6.6) kg m^- ²; 66% were females. Over 80% of patients attending the service lost some weight by 3 months. Average absolute weight loss was 4.11 (4.95) kg at 3 months and 6.30 (8.41) kg at 6 months, equating to 3.28% (3.82%) and 4.90% (6.26%), respectively, demonstrating a statistically significant weight change at both time points (P < 0.001). This meets NICE best practice guidelines for the commissioning of services leading to a minimum of 3% average weight loss, with at least 30% of patients losing at ≥5% of their initial weight. Waist measurement and BMI were reduced significantly at 3 months. Improvements were also seen in physical activity levels, fruit and vegetable consumption, and self-esteem levels (P < 0.001).

CONCLUSIONS

This service was successful in aiding weight loss in morbidly obese populations. The findings of the present study support the view that weight-loss targets of 3% are realistic.

Description and preliminary results from a structured specialist behavioural weight management group intervention: Specialist Lifestyle Management (SLiM) programme

BACKGROUND

Specialist Lifestyle Management (SLiM) is a structured patient education and self-management group weight management programme. Each session is run monthly over a 6-month period providing a less intensive long-term approach. The groups are patient-centred incorporating educational, motivational, behavioural and cognitive elements. The theoretical background, programme structure and preliminary results of SLiM are presented.

SUBJECTS/METHODS

The study was a pragmatic service evaluation of obese patients with a body mass index (BMI) ≥35 kg/m(2) with comorbidity or ≥40 kg/m(2) without comorbidity referred to a specialist weight management service in the West Midlands, UK. 828 patients were enrolled within SLiM over a 48-month period. Trained facilitators delivered the programme. Preliminary anonymised data were analysed using the intention-to-treat principle. The primary outcome measure was weight loss at 3 and 6 months with comparisons between completers and non-completers performed. The last observation carried forward was used for missing data.

RESULTS

Of the 828 enrolled within SLiM, 464 completed the programme (56%). The mean baseline weight was 135 kg (BMI=49.1 kg/m(2)) with 87.2% of patients having a BMI≥40 kg/m(2) and 12.4% with BMI≥60 kg/m(2). The mean weight change of all patients enrolled was -4.1 kg (95% CI -3.6 to -4.6 kg, p=0.0001) at the end of SLiM, with completers (n=464) achieving -5.5 kg (95% CI -4.2 to -6.2 kg, p=0.0001) and non-completers achieving -2.3 kg (p=0.0001). The majority (78.6%) who attended the 6-month programme achieved weight loss with 32.3% achieving a ≥5% weight loss.

CONCLUSIONS

The SLiM programme is an effective group intervention for the management of severe and complex obesity.

Weight related health status of patients treated by dietitians in primary care practice: first results of a cohort study

Background

Overweight and obesity are common in the Netherlands: in 2006 51% of adult men and 42% of adult women were overweight; 10% of men and 12% of women were obese. Patients with overweight or obesity in the Netherlands are often referred to dietitians in primary care for weight loss treatment. We followed a prospective observational cohort to study the effectiveness of this treatment and present the baseline results in this article.

Methods

We invited dietitians throughout the country, who completed at baseline a questionnaire for each patient including weight, stature, waist circumference, age, gender, morbidities, medication, education level, ethnicity, referral, treatment expectations, history of previous weight loss attempts, and exercise.

Results

At baseline data from 1546 patients were obtained from 158 dietitians working in 26 practices. The majority (73%) of patients were obese (BMI ≥ 30 kg/m²); and 10% had a BMI of 40 kg/m² or more. The majority of patients (94%) had a high to extremely high weight related health risk (WRHR): (BMI 25–30 kg/m² with comorbidities, or BMI 30–35 kg/m² without comorbidities, up to BMI ≥35 with comorbidities and BMI ≥40 with or without comorbidities). More than half (57%) had comorbidities and a long history of weight loss attempts. An extremely high WRHR was seen in 24.5% of the sample. Patients with very high to extremely high WRHR often had type 2 diabetes mellitus; hypertension; dyslipidaemia; osteo arthritis; and sleep apnoea. Patients of middle and old age had a higher risk for very high and extremely high WRHR. Those with other comorbidities and those who asked for referral themselves had a lower risk.

Conclusion

The study was effective in recruiting dietitians to participate. The sample is representative for dietitians working in primary care. The majority of patients (94%) had a high to extremely high weight related health risk (WRHR).

Intervenção nutricional pautada na estratégia de oficinas em um serviço de promoção da saúde de Belo Horizonte, Minas Gerais

OBJETIVO: Avaliar as oficinas como uma estratégia de intervenção nutricional, com foco na aquisição de informações em nutrição e na percepção de mudanças de hábitos alimentares. MÉTODOS: Estudo de intervenção com usuários de uma Academia da Cidade de Belo Horizonte, Minas Gerais. Realizaram-se quatro oficinas, com frequência mensal e duração de trinta minutos cada uma, pautadas no "Guia Alimentar para a População Brasileira" e nos "Dez Passos para uma Alimentação Saudável". Aplicaram-se questionários para avaliar a aquisição de informações em nutrição antes e depois da execução das oficinas, investigar a percepção de mudanças de hábitos alimentares após três meses da intervenção e identificar as principais dificuldades verificadas nesse processo. Um observador apontou a viabilidade de execução das oficinas. RESULTADOS: O número de participantes das oficinas variou de 71 a 132. Houve maior ocorrência (80%) de mulheres, com média de 55,8 (±10,6) anos. Identificou-se incremento estatisticamente significante na média total de acertos das questões do questionário de avaliação da aquisição de informações em três dos quatro encontros. Ademais, 90,9% dos participantes referiram alguma mudança de hábito alimentar, destacando-se a redução no consumo de óleos, gorduras e frituras (29,5%) e o aumento na ingestão de frutas e hortaliças (22,5%). A redução no consumo de açúcares e doces foi apontada como a recomendação mais difícil de ser seguida (21,1%). A avaliação do observador denotou a necessidade de modificar o espaço utilizado para as atividades. CONCLUSÃO: A intervenção apresentou potencial para aquisição de informações em nutrição e mudança de hábitos alimentares, alterações que devem ser mais bem investigadas com a continuidade das ações.

Gastrointestinal complications of obesity: non-alcoholic fatty liver disease (NAFLD) and its sequelae

Obesity is a major risk factor for malign and non-malign diseases of the gastrointestinal tract. Non-alcoholic fatty liver disease (NAFLD) is an outstanding example for the complex pathophysiology of the metabolic system and represents both source and consequence of the metabolic syndrome. NAFLD has a growing prevalence and will become the leading cause of advanced liver disease and cirrhosis. Obesity has a negative impact on NAFLD at all aspects and stages of the disease. The growing epidemic will strain health care resources and demands new concepts for prevention, screening and therapeutic approaches. A better understanding of the interplay of liver, gut and hormonal system is necessary for new insights in the underlying mechanisms of NAFLD and the metabolic syndrome including obesity. Identification of patients at risk for progressive liver disease will allow a better adaption of treatment strategies.

Gastric electrical stimulation for the treatment of obesity: from entrainment to bezoars-a functional review

GROWING WORLDWIDE OBESITY EPIDEMIC HAS PROMPTED THE DEVELOPMENT OF TWO MAIN TREATMENT STREAMS: (a) conservative approaches and (b) invasive techniques. However, only invasive surgical methods have delivered significant and sustainable benefits. Therefore, contemporary research exploration has focused on the development of minimally invasive gastric manipulation methods featuring a safe but reliable and long-term sustainable weight loss effect similar to the one delivered by bariatric surgeries. This antiobesity approach is based on placing external devices in the stomach ranging from electrodes for gastric electrical stimulation to temporary intraluminal bezoars for gastric volume displacement for a predetermined amount of time. The present paper examines the evolution of these techniques from invasively implantable units to completely noninvasive patient-controllable implements, from a functional, rather than from the traditional, parametric point of view. Comparative discussion over the available pilot and clinical studies related to gastric electrical stimulation outlines the promises and the fallacies of this concept as a reliable alternative anti-obesity strategy.