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

Additional FeesThe 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

Initial Consultation $280

Gastric Banding Surgery $18,500

Gastric Sleeve Surgery $20,750

Gastric Bypass Surgery $23,500

PHARMAC 2017 Year in Review

$74.46M

PHARMAC 2016 Year in Review

570,000

The prevalence of overweight and obesity in NZ adults by age group, 2016/17.

12.314.7

24.0

31.132.4 37.2 38.4 39.3 27.0

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Overweight Obesity

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.

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

Coppell K et al. NZ Med J, 2013

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 indexcategory (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 AdultsMinistry 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

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List of ‘fad’ diets• The 4-Hour Body

• 5:2 diet

• Alkaline diet

• Baby Food Diet]

• Blood type diet

• Cabbage soup diet

• Detox diet

• Dukan Diet Fruitarianism

• Gluten fee diet, while essential for people with coeliac disease or gluten sensitivity, has also been a fad.

• Grapefruit diet

• Israeli Army diet

• Juice fasting

• KE diet

• Macrobiotics

• Master Cleanse

• [Mediterranean diet]

• Morning banana diet

• Paleolithic diet

• Pritikin Diet

• Scarsdale medical diet

• South Beach Diet

• Superfood diet

• Veganism

• Ketogenic diet

• Low-carbohydrate diets • Atkins diet• Sugar Busters• Zone diet

• Whole30 diet

• High carb/low fat diets • Dr. Dean Ornish: Eat More, Weigh

Less• The Good Carbohydrate Revolution• the Pritikin Principle

• Food combining • Fit for Life• Suzanne Somers’ Somersizing

• Liquid diets• Cambridge Diet• Slim-Fast

• Diet pills, supplements and herbal remedies • Dexatrim Natural• HCG diet• Hydroxycut• Metabolife 356

https://en.wikipedia.org/wiki/Fad_diet#cite_note-Nestle2006-11

Diabetes Prevention Program (DPP)

Diabetes Prevention Study (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 weightreducing intake of total fat & saturated fatincreasing dietary fibre, andincreasing 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)

Ad

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Maruther et al. J Gen Intern Med 2013; 28: 1629-36

51%

Diabetes risk in the DPP by percent weight loss achieved at 6 months (mean follow-up 2.7 years)

Maruther et al. J Gen Intern Med 2013; 28: 1629-36

13% 6%

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 basisduring 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

“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.

Supplement—Nutrition Education in Training Medical and Other Health Care Professionals

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

Lifestyle

BudgetFamily &

Employment

Cultural background

Lifestyle questions

• Special Diet or food allergies (tick if applicable): Vegetarian, Vegan, Pescatarian (vegetarian + fish), Nut free, Dairy free, Gluten free , Etc

• Physical activity – frequency and type

• Please indicate who you live with?

• Who mostly buys food in your house?

• Who mostly cooks food in your house?

• Is your budget for food limited? On a scale of 1 - 10, how ready are you to make food changes (1 - not ready at all; 10 – really motivated)?

Weight History

• Has your weight tended to go up and down?

• How long have you been your current weight?

Clinical Notes – suggested optional questions

• What was a weight that you felt comfortable at?

• Where do you hope to be in 6 Months?

• Where do you hope to be in 2 Years?

Diet Assessment

• 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 meals 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, DilitazanHydrochloride, Atorvostatin, Nitrolingual spray.

Baseline Appointment

• HbA1c: XX mmol/mol

• Weight: 86.5 kg

• Waist circumference: 98 cm

• BP: 159/104 mmHg

• Weight loss goal 8.65kg

• Financial Stress.

• Non compliant with meds - GP appt.

Nutritional goals

1. Increase fruit to 2 servings daily.

2. Increase veges to 4 servings daily.

3. Reduce usual sugar in coffee by half to 2 tsp each cup.

2-3 week Appointment – attended with partner

• Weight increased by 2.5 kg

• BP: 159/110 mmHg

• Eating veges 3x daily

• Reduced sugar in coffee to 2 tsp per cup

• Decreased salt intake & eating fish 2x week

Revised nutritional goals

• New goal - source apples, bananas and mandarins. Eat 2x daily.

• Discussed Kia Ora community education programme.

• Appt made GP - WINZ and Kiwisaver.

• Referred to Social Worker.

• Refused smoking cessation support.

6 week Appointment

• Achieved previous nutrition goals

• Weight decreased to 83.5 kg

• Waist circumference decreased to 94 cm [4cm less than at baseline]

• BP 140/101 mmHg

• Waiting to hear back from Social Worker.

Revised nutritional goals

• Plan and prepare healthy snack options.

• Eat chips 1x week.

• Referred to Kia Ora programme.

Month Weight BMI HbA1c Goal 1 Goal 2 Goal 3

0 79.7 29.45 44 healthy takeaways, iesubway or turkish

healthier sweet options ie smoothie, fruit,

increase vege portions and decrease plate 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 vegetables to 7+ serves and fill half the meal plate with vegetables

To reduce amount of crackers per week to 2-3 times, alternate cheese with cottage cheese

Stop having desserts

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 bloodsHas 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 with type 2 diabetes: A systematic review and qualitative meta-synthesis. [Vanstone M, Rewegan A, Brundisini F, et al. Chronic Illn. 2017;13(3):217-235.]

• Five inter-connected barriers to diet modification that are magnified by social marginalization.

• Abel S, Whitehead LC, Coppell KJ. Making dietary changes following a diagnosis of prediabetes: a qualitative exploration of barriers and faciliators. Diabet Med. 2018 Aug 9. doi: 10.1111/dme.13796. [Epub ahead of print]

Dietary change

Self-discipline

Family and social

support

Social significance

of foodEmotions

Knowledge and

information

“Can look at a habit now and decide if I want to keep

it or change it.”

Collaborators

Trish Freer, Health Hawke’s Bay

Kiri Sharp, University of Otago

Joanna Norton, University of Otago

Sally Abel, Kaupapa Limited

Terry Spedding, Health Hawke’s Bay

Rachael Engelbrecht, Tamatea Medical Centre

Diane Stride, Diane Stride Dietitian

Lillian Ward, Health Hawkes’ Bay

Andrew Gray, University of Otago

Lisa Whitehead, Edith Cowan University, Australia

Trudy Sullivan, University of Otago

Leigh Perreault, University of Colarado

David Tipene-Leach, Eastern Institute of Technology

Tony Merriman, University of Otago

Jeremy Krebs, University of Otago

Angeline Tangiora, Health Hawke’s Bay

Postgrad Students

Deborah Connor, University of Otago

Research Assistant

Courtney Mizen, Edith Cowan University, Australia

AcknowledgementsPractice 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

…..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. Not here." She's lost some weight, and has not progressed to full diabetes. Overall, she found the experience "very useful“…….As you do it more and it starts becoming more second nature, it's just changing your style of living."

Napier 70-year-old Gayle Peters was told she was pre-diabetic about three years ago. With targeted diet advice, she reduced her sugar and carbohydrate intake and has not progressed to 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

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

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

Prevalence of obesity (BMI ≥30 kg/m2) among New Zealand men and women aged 15+ years

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