Overview of Non-Alcoholic Fatty Liver Disease (NAFLD) and ...
LIFESTYLE INTERVENTIONS FOR NON-ALCOHOLIC FATTY … conf 2/1400 kirsten coppell.pdfLIFESTYLE...
Transcript of LIFESTYLE INTERVENTIONS FOR NON-ALCOHOLIC FATTY … conf 2/1400 kirsten coppell.pdfLIFESTYLE...
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
0
10
20
30
40
50
60
70
80
90
100
0-14 15-17 18-24 25-34 35-44 45-54 55-64 65-74 75+
Pro
po
rtio
n (
%)
Age Groups
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.
0
10
20
30
40
50
60
15-24 25-34 35-44 45-54 55-64 65-74 75+
Pre
vale
nce
(%
)
Age groups (years)
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
0
1000
2000
3000
4000
5000
6000
7000
8000
1859
190
8
1914
1918
192
5
192
8
1932
1935
1938
194
2
194
5
194
8
1951
1954
1957
196
0
196
3
196
6
196
9
1972
1975
1978
198
1
198
4
198
7
199
0
199
3
199
6
199
9
20
02
20
05
20
08
20
11
20
14
20
17
Nu
mb
er
Year
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
just
ed H
azar
d R
atio
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
0
5
10
15
20
25
30
35
40
Prop
ortion
(%)
Year
Women Men