|
 
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| PRACTICAL APPROACH |
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| Year : 2017 | Volume
: 5
| Issue : 1 | Page : 28-34 |
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Dietary approach to manage obese patient
Majed M Alsaleh1, Abdullah M Algarni2
1 Ministry of Health, Saudi Arabia
2 General Directorate of Health Affairs in Aseer Region, Department of Public Health, Family Medicine Training Program, Abha City, Saudi Arabia
| Date of Web Publication | 13-Jul-2017 |
Correspondence Address:
Abdullah M Algarni
Family Medicine Training Program, 4076 - Al Muruj, Unit No. 3, Abha 62527-7638
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/sjo.sjo_8_17
Obesity is a common, major health problem. The trend of obesity incidence and prevalence in Saudi Arabia is alarming. Thoughts and behaviors are major risk factors for specifically obesity and overall health status. Hence, the lifestyle modification (dietary, physical activity, and other behavioral measures) is considered the first-line treatment in obese patient. Changing thoughts and behaviors are feasible function of primary care physician, although not easy at all time. The objective of this paper is to discuss the dietary management of obese patients using illustrated case scenario approach. Keywords: Nutritional approach, obese patient, obesity
How to cite this article:
Alsaleh MM, Algarni AM. Dietary approach to manage obese patient. Saudi J Obesity 2017;5:28-34 |
| Introduction | |  |
The estimated prevalence of overweight and obesity in Saudi Arabia is 30.7 and 28.7%, respectively.[1] Obesity affects almost every organ system of the human body, and its effect appeared to be mediated largely, but not solely, by the metabolic burden of the excessive adipose tissues.[2] Obesity is a direct reflection of patient behaviors and culture, rather than an isolated biological issue. So it is not surprising that failure of obesity management is inventible if treated only as an isolated biological issue. Management of obesity can be broadly divided into nonpharmacological, pharmacological, and surgical treatment. Nonpharmacological (or lifestyle modification) management is a combination of diet, exercise, and behavioral interventions.[3],[4] Comprehensive lifestyle modification was more effective in prevention of type 2 diabetes mellitus than pharmacologic intervention.[5]
In this article, we will discuss the dietary management of obese patients using illustrated case scenario approach.
| Dietary therapy | | |
General principles
It is important to set goals when discussing a dietary weight loss program with an individual patient. The first goal of any overweight individual is to prevent further weight gain. The realistic weight loss goal is 5 to 7% of body weight. Most patients have a weight loss goal of at least 30%, which is unrealistic.[6] The role of family physician is to identify and review with the patient a realistic weight-loss goal. A successful program will lead to a weight loss of more than 5% of initial weight.[7] If this goal achieved, it can reduce risk factors of cardiovascular disease, such as dyslipidemia, hypertension, and diabetes mellitus.[8]
Types of diets
Excess intake of calories from any source, beside a sedentary lifestyle, causes weight gain and obesity. The goal of dietary therapy, therefore, is to reduce the total number of calories consumed. A principal determinant of weight loss appears to be the degree of adherence to the diet, irrespective of the particular macronutrient composition.[9],[10],[11],[12] Thus, choosing a diet or eating plan is better to be on the basis of patient preferences, which may improve long-term adherence. The diet should emphasize reductions in refined carbohydrates, processed meats, and foods high in sodium and trans fat; moderation in unprocessed red meats, poultry, eggs, and milk; and high intakes of fruits, nuts, fish, vegetables, vegetable oils, minimally processed whole grains, legumes, and yogurt.[13]
Conventional diets are defined as those with energy requirements above 800 kcal/day.[14] These diets fall into the following groups:- Balanced low-calorie diet: It contains a mixture of adequate amount of macronutrients (i.e., carbohydrates, protein, and fat).
- Low-fat diet: All dietary guidelines recommend decreasing fat intake by at least 30% of energy intake.[15] So for every 1000 kcal, it contains 33 g of fat. Low-fat diet decreases weight more than moderate-fat diet.
- Low-carbohydrate diet: It is important for short-term weight loss. This diet can decrease the risk of T2DM, ischemic heart diseases, and some cancers. Very low-carbohydrate diets (i.e., <50 g/day) associated with ketosis because of glycogen mobilization. Low-carbohydrate diet can be achieved by decreasing total amount of carbohydrate or taking foods that contain low glycemic index.
- Mediterranean diet: There is some variation in Mediterranean diets; however, common components are as follows:
- High level of monounsaturated fat relative to saturated.
- High consumption of vegetables, fruits, legumes, and grains.
- Moderate consumption of milk and dairy products, mostly in the form of cheese.
- Relatively low intake of meat and meat products.
The Mediterranean diet appears to be associated with several health benefits, including cardiovascular risk reduction and diabetes prevention.[16],[17]
Fad diets are diets that lead to rapid weight loss but without scientific background. Although they are popular, their long-term effectiveness is questionable.[18]
How dietary therapy decreases weight?
Weight loss is directly related to the difference between the patient’s energy intake and energy requirements. Reducing caloric intake below expenditure results in a predictable initial rate of weight loss that is related to the energy deficit.[4],[19] However, prediction of weight loss for an individual patient can be difficult because of significant interpatient variability in initial body composition, adherence, and energy expenditure.[19],[20] Food records are often inaccurate. Most normal-weight people underreport what they eat by 10 to 30%, whereas overweight people underreport by at least 30%.[21]
Approximately 22 kcal/kg is required to maintain a kilogram of body weight in a normal adult. Thus, the expected or calculated energy expenditure for a woman weighing 100 kg is approximately 2200 kcal/day. An average deficit of 500 kcal/day should result in an initial weight loss of approximately 0.5 kg/week. However, after 3 to 6 months of weight loss, energy expenditure adaptations occur, which slow the bodyweight response to a given change in energy intake, thereby diminishing ongoing weight loss.[20]
Estimation of energy expenditure
There are several methods of formally estimating energy expenditure; the most widely used criteria are the World Health Organization criteria shown in [Figure 1] and [Table 1]. This method allows a direct estimation of resting metabolic rate [basal metabolic rate (BMR)] and calculation of daily energy requirement on the basis of activity level of the patient.[22] | Figure 1: Steps of calculating basal metabolic rate and total energy expenditure
Click here to view |
 | Table 1: Revised World Health Organization (WHO) equations for estimating energy expenditure[23]]
Click here to view |
It is important for the overweight patient to understand that achieving and maintaining weight loss is made difficult by the reduction in energy expenditure that is induced by weight loss.[24] Weight loss maintenance is also difficult because of changes in the peripheral hormone signals that regulate appetite.[25]
In the following section, we are going to display a nutritional approach using five-As counseling strategy for an obese patient.[26],[27]
| Case scenario | | |
Mr. Faisal is a 29-year old Saudi male who came to your clinic for health promotion and annual check-up. You noted that he was obese; as family physician, how can you use dietary approach in five-As format to help Faisal to reduce his weight?
Initial visit
Family physician should start consultation by welcoming Faisal, thanking him for attendance the clinic, and establishing with him a good rapport to conduct a successful consultation. Family physician decided to discuss with Faisal his weight in the current visit. He asked Faisal whether he is interested to discuss his weight and his readiness to work on it at that visit (Ask). Faisal responded positively; at that moment, family physician started to collect bio-data and asked an open-ended question. Faisal ideas and concerns were adequately explored, as the real reason and expectation from this visit were important issues to be addressed in initial visit.
| Present illness history and systemic review | | |
Present complaint and past medical history, and dietary and physical activities were covered completely (Assess) by focusing on the following important points[28]:- Social history to check level of education, financial status, nature of Faisal’s job, smoking, alcohol, and substance abuse.
- Duration of obesity.
- Onset of obesity, and factors increasing and decreasing weight.
- Effects of obesity on Faisal’s health and his quality of life.
- Detailed dietary history include number of meals, snacks, intake fast food, intake soft drinks, taking breakfast regularly, and intake of fruits and vegetables.
- Exploring daily physical activity, practicing sport (type, frequency, and duration), and watching Television (TV) or gaming on play stations, if any.
- Family history of chronic diseases such as obesity, diabetes, hypertension, dyslipidemia, and cardiovascular diseases were covered completely.
- Psychiatric history to uncover mood change, psychotic disorders, personality disorder, and eating disorders.
Detailed history from Faisal showed that he is a 29-year-old working accountant in a local bank. He is in good health status generally but gained weight for the last 5 years; dietary history revealed that Faisal intakes soft drink like sweet juices and cola. Most of the days, Faisal has breakfast at home with his family. After returning to home, Faisal has his launch consisting Kabsa, soft drink, and sometimes milk. There was less than 1 to 2 serves per week of fruits and vegetables. Faisal sleeps usually for 2 h before getting up to finish personal and family duties. Faisal watches TV for about 3 h without performing any physical activity. Weekly, he meets his friends at night and has dinner together. The dinner differs but usually consists Kabsa or roasted goat. While watching TV, Faisal eats some dates and sweets with Arabic coffee and tea. There was no history of fatigue, hair loss, diarrhea, or constipation. Faisal’s mood was normal with no relevant stressor. Faisal addressed his concern about night snoring only. Family history revealed that Faisal’s father and mother are diabetic, hypertensive, and obese on medications. There is neither any history of smoking in the family and nor any conflict with income for family needs. Faisal’s performance at work is good, although he sometime suffered from somnolence and recurrent yawing. However, he can cope with that issue.
| Physical examination | | |
After taking comprehensive history, family physician performed a comprehensive physical examination after taking the permission of Faisal and explaining to him what he is going to do. The physical examination covered the following aspects:- General look and body built
- Vital signs [including weight, height, and body mass index (BMI)]
- Thyroid and neck examination
- Heart and chest
- Abdomen including waist/hip ratio
- Back and joints
- Skin
Physical examination of Faisal revealed the following finding:
Faisal looking obese, with a normal gait, not jaundiced or pallor, and there was no skin pigmentation, lesions, or scars. There was no acanthosis nigricans noted. Vital signs were as follows:- BP = 134/81 mmHg
- Temperature = 36.1°C
- Weight = 87 kg
- Height = 170 cm
- BMI = 30.1 kg/m2, and
- Waist circumference= 103 cm.
Head, neck, ENT, and thyroid were normal; heart and chest examination showed no abnormality or significant finding. Abdomen showed central obesity but no organomegaly. There was no lower limb swelling or deformity.
The family physician appreciated Faisal’s cooperation during history taking and physical examination. Family physician explained the findings to Faisal; he stated that his weight was above normal, and there is no obvious cause for weight gain except the intake of unhealthy diets and physical inactivity. Family physician told Faisal that snoring as well as somnolence and recurrent yawing is most likely due to his weight, and those with abnormal weight are at high risk of diabetes, hypertension, and dyslipidemia. Family physician informed Faisal that relevant investigations are necessary to rule out secondary causes of obesity and to screen for some health problems, such as hypothyroidism, diabetes, and dyslipidemia.
Faisal agreed with his family physician diagnosis and mentioned his dream to have healthy weight. Family physician aimed to maintain the rapport with patient and tried to deliver the important information about obesity in an indirect way to avoid shocking the patient. The family physician explained to Faisal that obesity is a systemic disease, affecting almost all systems in body, and it is not just isolated increase in weight. He provided Faisal with educational materials as well as some social media accounts important for obesity. The family physician thanked Faisal and gave him an appointment after 2 weeks to complete discussion and check the results of investigations.
| Investigations | | |
At this visit, the following investigations were requested:- Fasting blood glucose.
- Lipid profile.
- Thyroid functions test.
- Liver functions test.
Second visit
Faisal came on time for follow-up. Family physician greeted Faisal and thanked him for attendance. Brief history was taken, and weight and height were noted to calculate the BMI. The results of investigation were normal. Faisal mentioned that he read the educational materials. He wondered if the mentioned risks in the materials about obesity were supported by evidences. The family physician grabbed the opportunity and started to mention the evidences that support the detrimental effects of being obese as well as benefits of healthful weight in simple and understandable way (Advice). Also he listed obese patients’ experiences before and after weight reduction in meaning of improving quality of life and ameliorating sleep-related complaint (snoring).
Again family physician gave Faisal educational materials rich in studies that demonstrated harmful effects of obesity, benefits of healthful lifestyle, management strategies as well as a book, in which a previously obese person narrated his experience before and after weight reduction. Family physician gave Faisal appointment after 2 weeks and thanked him for attending the clinic.
Third visit
Faisal came to his family physician seeking eagerly a management plan to reduce his weight. He asked if there is any prepared plan that can be used to decrease his weight (Agree). Family physician discussed with Faisal the following approaches, pros and cons, and evidences supporting each of them[3]:- Lifestyle modification.
- Pharmacotherapy.
- Metabolic surgeries.
They agreed then to start by lifestyle modification as initial intervention (Assist). Family physician explained the dimension and meaning of lifestyle modification in the following practical steps:[3],[28]- For physical activity:
- Participate in at least 60 min of moderate-to-vigorous physical activity per day for 5 days/week, and no more than 2 days without exercise is allowed.
- Use proper shoes and choose proper time for practicing exercise.
- Do not practice exercise after heavy meal. If there is a chest pain, stop and seek medical advice.
- Increase his daily activity through climbing stair instead of using elevators, park the car far from market during shopping, walk to mosque instead of using car, and participate in home tasks, for example, cleaning the car.
The following calculation were done by the family physician and Faisal to adjust the dietary therapy [Table 1]:[23][25]- Basal metabolic rate (BMR)=[(0.0630 × Faisal’s weight in kg) + 2.8957] × 240
= [(0.0630 × 87 kg) + 2.8957] × 240
= (5.481 + 2.8957) × 240
= 8.3767 × 240
= 2010.41 kcal/day - Total energy expenditure=BMR × activity factor
= 2010.41 × 1.3 (low as he is not exercising)
= 2613.53 kcal/day - They set a target of weight loss of 2 kg/month, that is, 0.5 kg/week, and the final goal is to lose 20 kg, which will bring his BMI to 23.2 kg/m2, so a duration of 10 months is set as the time needed to achieve the shared goal.
- Family physician explained to Faisal that rate of weight loss is directly related to the difference between total energy expenditure and daily intake of calories. He emphasized also the importance of realistic target and action plan. They agreed to decrease daily calories consumption by 500 kcal/day to achieve reduction in weight by 0.5 kg/week; so the daily intake of Faisal will be = 2000 kcal/day.
- Family physician provided Faisal with a table containing suggested meals that provide adequate macronutrients and micronutrients as well as meet the targeted goal (i.e., 2000 kcal/day) see Supplementary Appendix [Additional file 1].
The family physician and Faisal also discussed the following practical advices:[28]- Limit meals outside the home like fast food.
- Have family meals at least 5 to 6 times/week.
- Drink a glass of water before each meal and decrease salt in food to avoid fluids retention in the body.
- Eat slowly and grind food well.
- Do not fill the stomach or satisfy the palate with a large amount of food.
- Eat five or more servings of fruits and vegetables daily.
- Use television and computer for no more than 2h/day.
- Do not consume sugars-sweetened beverages (e.g., Pepsi, Coca Cola, energy drinks, etc.).
- Eat breakfast daily and use low-fat or fat-free milk and whole grain bread.
- Eat two to three meals per week containing fish.
- Eat three main meals and two healthy snacks.
- Reduce oil when cooking.
Faisal showed genuine interest in the action plan. He promised his family physician to adhere to the action plan, contact the family physician for any complaint or issue, and to come back after 1 month.
Fourth visit
This visit was the first visit after the action plan was agreed. So the family physician was interested in this visit, specifically to assess Faisal’s adherence to action plan and any complaint or active issue.
There was no active issue or complaint. Faisal was happy as he achieved (2 kg) weight reduction. The family physician was happy with that achievement and encouraged Faisal to continue in same manner. Then he checked with Faisal the logbook for diet and physical activity. The adherence to the action plan was in general excellent with promising results. The family of Faisal was supporting for his goal of weight reduction. The action plan was reviewed with Faisal to fill the gaps and solve challenging problems.
At the end of the visit, the family physician congratulated Faisal for his achievement and told him to return or contact the clinic if any issue or problem is faced. The next visit was agreed to be after 2 months.
Fifth visit
Family physician welcomed Faisal at his clinic as he attended on time. He praised Faisal for his punctuality. Brief history and physical examination were undertaken as well as the weight and BMI. The new weight was 81 kg and BMI = 28.02 kg/m2 (4 kg weight loss since previous visit).
Faisal wondered if he can use weight reduction medications as they will accelerate the loss of weight process. The family physician discussed with Faisal the pros and cons of such interventions. He provided him by scientific evidences, in simple language, that drug therapy for obesity should be for patients who did not achieve the optimum weight reduction with lifestyle modification.[3] He decided to continue vigorously exercising and dieting as he satisfied with the evidence introduced by his family physician and productive discussion. The family physician thanked Faisal and agreed to meet him again after 2 months.
Sixth visit
After checking the vital signs, weight and height were taken and BMI was measured. Faisal met his family physician with new look as he lost 5 kg since last appointment. His weight was 77 kg and BMI = 26.64 kg/m2. Faisal was very grateful to his family physician as he helped him in changing his thoughts about obesity as well as unhealthy behaviors. He mentioned that many aspects of his life were changed and improved surprisingly. His mood, sleep quality, daily activity, concentration, and achievement in work all were changed and improved. He conveyed to Faisal that he did a great job, as he arrived at this weight. He promised him with more improvement in his quality of life after completion of the action plan. An appointment was given to Faisal after 3 months as he will go to annual vacation. The physician provided Faisal with tips about social events participation, as it may detrimentally affect the agreed action plan for weight reduction, especially the dietary therapy.
Telephone consultation
After 6 weeks, the physician contacted Faisal on his mobile and discussed with him recent changes and obstacles regarding his lifestyles in the vacation. Faisal reported some difficulties in meaning of maintain the healthy diet during social events. But overall, he lost 3 kg during the past weeks. Family physician encouraged Faisal to make the weight reduction top priority to achieve the target smoothly. He reassured Faisal that some regress during implication of weight reduction action plan is normal and commonly expected. So what Faisal needs to do is maintaining a strong desire to change and never give up. He provided him with some tips before and after participation in social events, such as drinking water, vegetables, and juices before going to events. The physician stressed on keeping contact with him easy at any time he need such thing. Faisal thanked the physician for his attention and promised his physician to adhere to the action plan as was agreed before.
Seventh visit
Faisal came to the clinic on time. Brief history as well as physical examination was undertaken. Faisal’s weight at this visit was 73 kg and BMI=25.3 kg/m2. There was no active complaint or active issue. Family physician thanked Faisal for his adherence to the action plan despite facing challenges during the vacation. Hopefully, Faisal’s wife as well as two of Faisal’s brothers started to follow the action plan to reduce their weight. Faisal encouraged by his family physician to continue in same manner to achieve the agreed goal and work with his wife as well as his brothers. The physician thanked Faisal and gave him an appointment after 2 months.
Eighth visit
The physician welcomed Faisal at the door of clinic. A nurse checked his weight and height, and the reviewed the action plan together. His current weight was 69 kg (4 kg lost) and BMI=23.9 kg/m2. New appointment for Faisal was given after 2 months.
Ninth visit
Faisal entered the clinic saying, “finally doctor, I have reached the goal.” The physician congratulated and celebrated with Faisal for his achievement and patience for this successful and long journey of attitude and behavioral change. Faisal’s weight at that moment was 74 kg (5 kg lost) and BMI = 22.14 kg/m2. Family physician encouraged Faisal to continue in a lifelong healthy lifestyle to maintain his weight and prevent relapse. The physician told Faisal that his clinic and telephone is available at any time for assistance and give him appointment after 6 months for follow-up.
| Conclusion | | |
Obesity is multisystemic disease that requires multidisciplinary, comprehensive approach. It is better to be managed by a family physician, dietitian, and psychologist. However, in most instances, family physician can manage obese patients successfully if the multidisciplinary team is not available. Failure in changing behaviors is expected. Patience and cooperation with the patient are strongly recommended, as they will make management of obesity easier.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1]
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