Medical Nutrition Therapy in Obesity – A Person-centred Approach

Obesity has reached pandemic proportions globally and is rapidly increasing even in developing countries.^1,2 More recent research on this subject has improved the understanding of its pathogenesis and it is no longer considered due to a simple mismatch between diet and exercise. The current understanding of obesity suggests a more complex involvement of neuronal networks, underlying genetic predisposition and its interaction with environmental influences.³ Moreover, the clinical phenotype may range from a normal weight phenotype to morbidly obese individuals, further determined by ethnicity-specific variations.^4,5 However, irrespective of these disparities, lifestyle management, including medical nutrition therapy, remains the cornerstone of management.⁶

A practical approach for person-centred medical nutrition therapy  

Personalised dietary advice goes a long way in achieving, and more importantly maintaining, weight loss, than many other fad diets that are widely publicised today. Recently, in a study on morbidly obese individuals, we found that a large proportion of these individuals suffer from multiple psychological problems and may have different limitations in following a standard dietary advice.^7,8 This calls for personalised strategies to achieve patient-specific goals. The following are the three cardinal steps in prescribing a patient-centric dietary advice.

Step one: Understanding the patient’s current dietary habits and household practices

To prescribe personalised dietary advice, it is important to understand the patient’s daily household and ethnic dietary practices. In addition to gathering conventional information, it is important to understand the macronutrient breakdown, meal timings, monthly cooking-oil usage, frequency of eating fast food and co-morbidities of other family members.^9,10

Step two: To incorporate key principles promoting weight loss without major disruptions to the family’s meal pattern

It is important to emphasise the key dietary principles promoting weight loss, such as calorie restriction, enhanced protein intake, reduced consumption of oil and fattening foods, meal replacements etc. However, in order to ease initiation and long-term adherence of such a dietary prescription, it may be good to initiate the plan using similar foods that are made at home, but suggest changing their proportions. We have previously found that by altering the carbohydrate-to-protein ratios to those of normal recommended proportions in each meal, improves the satiety and glycaemic excursion in patients with diabetes.¹¹ The advent of mobile health applications has made choosing food items of similar calorie and macronutrient intake, more achievable for the patient.

Step three: Follow-up and address patient concerns and obstacles that arise during subsequent visits

Though a comprehensive dietary plan may have been suggested at the first visit, it is important to encourage patients to note the obstacles and concerns that they may experience with these plans, such that they can be discussed during subsequent follow-up.

Summary

The future of personalised medical nutrition therapy lies with nutrigenetics, the field where dietary advice could be provided based on the personalised genomic evaluation of the patient. But until that becomes a reality, these dietary principles go a long way in achieving the person-centred medical nutrition therapy for the management of obesity.

References

1. Kapoor N, Inian S, Thomas N. Obesity with Diabetes. In: Thomas N, Kapoor N, Velavan J, Vasan S. A Practical Guide to Diabetes Mellitus, 7^th edn. New Delhi, India: Jaypee Brothers Medical Publishers. 2016;463–77.
2. Afshin A, Forouzanfar MH, Reitsma MB, et al. Health effects of overweight and obesity in 195 countries over 25 years. N Eng J Med. 2017;377:13–27.
3. Kapoor N, Chapla A, Furler J, et al. Genetics of obesity in consanguineous populations–A road map to provide novel insights in the molecular basis and management of obesity. EBioMedicine. 2019;40:33–4.
4. Kapoor N, Furler J, Paul TV, et al. Normal weight obesity: an underrecognized problem in individuals of South Asian descent. Clin Ther. 2019;41:1638–42.
5. Kapoor N, Furler J, Paul TV, et al. Ethnicity-specific cut-offs that predict co-morbidities: the way forward for optimal utility of obesity indicators. J Biosoc Sci. 2019;51:624–6.
6. Kapoor N, Furler J, Paul TV, et al. The BMI–adiposity conundrum in South Asian populations: need for further research. J Biosoc Sci. 2019;51:619–21.
7. Jiwanmall SA, Kattula D, Nandyal MB, et al. Psychiatric burden in the morbidly obese in multidisciplinary bariatric clinic in South India. Indian J Psychol Med. 2018;40:129–33.
8. Ramasamy S, Kapoor N, Joseph M, et al. Health related quality of life in morbidly obese women attending a tertiary care hospital in India. Ann Glob Health. 2017;83:178.
9. Joseph M, Kapoor N, Ramasamy S, et al. Nutritional profile of the morbidly obese patients attending a bariatric clinic in a South Indian tertiary care centre. Obesity and Metabolism. 2017;14:41–7.
10. Deshpande NR, Kapoor N, Syed A, et al. Determinants of obesity in adolescent Asian Indian population. Endo Rev. 2013;34(Suppl 1):i360.
11. Deshpande NR, Patankar N, Kapoor N, et al. Effect of altering the dietary carbohydrate to protein ratio on body composition and glycemic control in type 2 diabetes. Obesity. 2010;18(Suppl 2):S214–5.

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Published: 17 January 2020