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Consensus on Medical Nutrition Therapy for Diabesity (CoMeND) in Adults: A South Asian Perspective

Authors Kapoor N, Sahay R, Kalra S, Bajaj S, Dasgupta A, Shrestha D, Dhakal G, Tiwaskar M, Sahay M, Somasundaram N, Reddy R, Bhattacharya S, Reddy VB, Viswanathan V, Krishnan D, Baruah M, Das AK

Received 26 August 2020

Accepted for publication 24 February 2021

Published 16 April 2021 Volume 2021:14 Pages 1703—1728

DOI https://doi.org/10.2147/DMSO.S278928

Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 2

Editor who approved publication: Professor Ming-Hui Zou

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Nitin Kapoor,1,2 Rakesh Sahay,3 Sanjay Kalra,4 Sarita Bajaj,5 Arundhati Dasgupta,6 Dina Shrestha,7 Guru Dhakal,8 Mangesh Tiwaskar,9 Manisha Sahay,10 Noel Somasundaram,11 Ravinder Reddy,12 Saptarshi Bhattacharya,13 Vijaya Bhaskar Reddy,14 Vijay Viswanathan,15 Dharini Krishnan,16 Manash Baruah,17 A K Das18

1Department of Endocrinology, Christian Medical College, Vellore, Tamil Nadu, India; 2Non Communicable Disease Unit, The Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia; 3Department of Endocrinology, Osmania MedicalA30 College, Hyderabad, Telangana, India; 4Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India; 5Department of Medicine, Moti Lal Nehru Medical College, Allahabad, Uttar Pradesh, India; 6Department of Endocrinology, Rudraksh Superspecialty Hospital, Siliguri, West Bengal, India; 7Department of Endocrinology, Hospital for Advanced Medicine and Surgery (HAMS), Kathmandu, Nepal; 8Department of Medicine, Khesar Gyalpo University of Medical Sciences, Thimphu, Bhutan; 9Department of Diabetology, Shilpa Medical Research Centre, Mumbai, Maharashtra, India; 10Department of Nephrology, Osmania Medical College and Osmania General Hospital, Hyderabad, Telangana, India; 11Department of Endocrinology, National Hospital of Sri Lanka, Colombo, Sri Lanka; 12Department of Gastroenterology, CARE Super Specialty Hospital & Transplant Centre, Hyderabad, Telangana, India; 13Department of Endocrinology, Max Superspeciality Hospital, Delhi, India; 14Department of Endocrinology, Government General Hospital, Pondicherry, India; 15Department of Medicine, M.V. Hospital for Diabetes & Prof M Viswanathan Diabetes Research Centre, Chennai, Tamil Nadu, India; 16Department of Food, Nutrition and Dietetics, Laksha Hospitals, Chennai, Tamil Nadu, India; 17Department of Endocrinology, Excel Care Hospitals, Guwahati, Assam, India; 18Department of Medicine, JIPMER, Puducherry, India

Correspondence: Sanjay Kalra
Bharti Hospital, Kunjpura Road, Model Town, Near State Bank of India, Sector 12, Karnal, Haryana, 132001 Tel +91 9896048555
Email [email protected]

Abstract: Diabetes and obesity are both increasing at a fast pace and giving rise to a new epidemic called diabesity. Lifestyle interventions including diet play a major role in the treatment of diabetes, obesity and diabesity. There are many guidelines on dietary management of diabetes or obesity globally and also from South Asia. However, there are no global or South Asian guidelines on the non-pharmacological management of diabesity. South Asia differs from the rest of the world as South Asians have different phenotype, cooking practices, food resources and exposure, medical nutrition therapy (MNT) practices, and availability of trained specialists. Therefore, South Asia needs its own guidelines for non-pharmacological management of diabesity in adults. The aim of the Consensus on Medical Nutrition Therapy for Diabesity (CoMeND) in Adults: A South Asian Perspective is to recommend therapeutic and preventive MNT in the South-Asians with diabesity.

Keywords: diabesity guidelines South Asia, medical nutrition therapy South Asia, nutrition therapy for obesity, nutrition therapy for diabetes, diabetes, obesity and diabesity

Introduction

Diabetes and obesity are showing a rising trend and giving rise to a new epidemic called diabesity.1 One in every ten individuals in the United States suffers from diabetes, and about 90–95% of them have type 2 diabetes (T2DM).2 About 79% of individuals with diabetes live in low and middle income countries (LMIC).3 Diabetes is reaching epidemic proportions in all South Asian countries, and more so in India, Pakistan and Bangladesh (Table 1).3 If this trend continues, India is projected to have approximately 101 million and 134 million adults with diabetes by 2030 and 2045, respectively.1,3

Table 1 Diabetes and Obesity Burden in South Asia

The rising trend in obesity in LMICs of South Asia (Table 1) is linked to improved socioeconomic status, increase in sedentary lifestyle and adoption of a calorie-rich Westernized diet.4,5

Background and Rationale

This guideline is prepared to address many gaps in the current day practice of non-pharmacological management of diabesity. There are many guidelines on dietary management of diabetes or obesity globally and also from South Asia. However, there are no guidelines or recommendations that address both diabetes and obesity and thus diabesity in the South Asian region. Additionally, the existing diabetes and obesity guidelines have more data from the West and minimal data from South Asia.

The South Asian phenotype is very different from the rest of the world. Normal weight obesity (the lean-obese) is a common phenotype in South Asia.6,7 South Asian adults have higher body fat, lower skeletal mass, more visceral obesity, higher abdominal obesity, more ectopic fat deposition (in liver, muscle etc) and less subcutaneous fat space at the same or lower body mass index (BMI) as compared to the Western world.5,6,8,9 Many of these characteristics are genetically determined and unique to the South Asian phenotype.10

Even though the dishes from different countries of South Asia look different, they usually have similar macronutrient content across the region. Though the diet in South Asia is often on the higher calorie side (sometimes >3000 calories/day), it does not meet the protein requirements of adults. The South Asian diet is rich in carbohydrates, refined sugar, and processed food and low in fiber, fruits and vegetables. Deep frying, reusing oil for cooking and higher use of trans-fats is common in South Asia.11 These dietary practices are very different from Western dietary practices.

South Asia is also witnessing increased exposure to the food industry. This along with an increasingly sedentary lifestyle in this region is complicating the diabesity problem further. There is an urgent need to curb this using technology. One way to utilize technology is to use smartphone applications (apps) that track nutrients, food labels, calorific value of food, footsteps, exercise level, etc and offer custom-made solutions. However, these apps have not been properly integrated in the management of diabesity.

Another unique feature in South Asia is paucity of specialists. The majority of individuals with diabetes, obesity and diabesity are managed by their primary care physicians. With few specialists in South Asia, it is difficult to give person-centric care. Hence, there is an urgent need to formulate practice guidelines for the physicians to follow. Smartphone apps can help patients maintain a healthy diet and lifestyle. They can be useful tools to provide patient-centric care to manage day to day nutrient intake and calorie intake and expenditure.

Medical nutrition therapy (MNT), or dietary advice given by a trained health care professional (HCP), plays a significant role in management of diabesity. However, MNT lacks proper understanding and a structured delivery approach in South Asia. Hence, there is a felt need to train more physicians in diabesity MNT care in South Asia.

Thus, South Asia needs its own guidelines for non-pharmacological management of diabesity in adults due to various reasons discussed in this section. The aim of the Consensus on Medical Nutrition Therapy for Diabesity (CoMeND) in Adults: A South Asian Perspective is to recommend therapeutic and preventive MNT in South Asians suffering from diabesity.

Methodology

A group of general medicine, endocrine and obesity experts from South Asian countries, that is, Bangladesh, Bhutan, India, Nepal and Sri Lanka, met on January 17, 2020 to frame the Consensus on Medical Nutrition Therapy for Diabesity (CoMeND) in Adults: A South Asian Perspective.

Global and South Asian data on diabetes and obesity was reviewed in detail prior to the meeting. The following guidelines were studied in detail: the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) clinical practice guidelines for obesity, the American Diabetes Association (ADA) Standards of Medical Care in Diabetes for “Obesity Management for the Treatment of Type 2 Diabetes” and “Lifestyle Management”,12,13 a position statement from the Academy of Nutrition and Dietetics,14 the Research Society for the Study of Diabetes in India (RSSDI) clinical practice recommendations for the management of type 2 diabetes mellitus,15 other food-based dietary guidelines,16 the European Association for the Study of Obesity (EASO) position paper,17 and guidelines and recommendations for South Asia and India. Several review articles and landmark trials on non-pharmacological management of obesity/diabetes/diabesity were also reviewed for formulating the Consensus.1,5,18–23 Patient-centered care and its benefits in diabesity were also explored.24–27

The first draft of the recommendations was prepared and circulated amongst the experts prior to the meeting for their detailed review. At the meeting, the experts provided suggestions, comments and opinions on the draft. The draft was then revised based on the discussions during the meeting and re-circulated among the experts for their final suggestions. Post this, the draft was finalized and approved by the experts and sent for publication.

Overview of Recommendations

The recommendations on non-pharmacological management of diabesity in adults are considered under the following headings:

  1. Screening and Diagnosis
  2. Staging
  3. Medical Nutrition Therapy
    • Definition
    • Indications
    • Goals
    • Types of Diets
    • Integrated Approach
    • Components
    • General Recommendations
  4. Managing diet in a setting of abundance
  5. Monitoring
  6. Counselling and Motivation
  7. Way Forward: Personalized Medicine and Person-centered Care

Also, approximate calorific values of some cooked food preparations are provided in Appendix I.28

Screening and Diagnosis

Recommendation for Screening and Diagnosis

For screening and diagnosis of diabesity, the following should be done:5,29

  1. History: Detailed history is taken to find the root cause of weight gain (Figure 1). This helps individualize patient treatment based on the identified causes.30
  2. Physical exam: Double chin, dorsocervical pad of fat, ectopic fat as in sub-scapular, axillary and infra-axillary regions are seen in South Asians. Other things that should be looked for are acanthosis nigricans, xanthelasma, arcus, tendon xanthoma, abdominal striae, gynecomastia, thyroid nodules/swellings.
  3. Anthropometry: Height, weight, waist circumference, waist:hip ratio, and body mass index (BMI) should be measured. Other optional investigation: percentage body fat. The South Asian ethnicity specific cut-offs should be used for these obesity indicators as proposed below:31
    • BMI of ≥23 kg/m2 should be considered as overweight and ≥25 kg/m2 as obese (Table 2). This is in agreement with ADA, WHO and Indian consensus group recommendations for BMI cut-off in Asians.21,32–34
    • At BMI of ≥23 kg/m2 screening for diabetes should be initiated.21,32
    • Waist circumference indicates visceral fat and is a useful predictor of cardiometabolic risk and can be combined with BMI. It can be measured at regular intervals to note decrease in visceral fat.35
    • Other anthropometric measures which can be combined with BMI include: the ratio of waist circumference to hip circumference (waist:hip ratio ([WHR]), and the ratio of waist circumference to height (waist:height ratio).36
    • Body fat percentage and visceral adipose tissue estimation, though currently used only in the research setting, has significant relevance in the South Asian population.6 As per the American Society of Endocrinologists, the cut-off for total body fat percentage is 35% for women and 25% for men; however, for Asians, a cut-off of 20.6% in men and 33.4% in women has been suggested.7
  4. Laboratory tests: Glycated hemoglobin (HbA1c), fasting and postprandial glucose, fasting lipid panel and albumin/creatinine ratio should be done. Based on clinical suspicion, other assessments may include uric acid, hepatic transaminases and serum cortisol.
  5. The 4 Ms of assessment: The complete diabesity assessment framework should consider the 4 Ms: Metabolic, Mechanical, Mental and Monetary (Table 3).This helps in holistic management of the patients.30

Figure 1 Root causes of diabesity. Notes: Data from Kapoor et al.30

Table 2 Body Mass Index (BMI) Criteria for Obesity in Adults

Table 3 The 4 Ms of Diabesity Assessment

Limitations of Obesity Assessment Measures

Physicians often use only BMI for measuring obesity. Though BMI is a very popular method of assessing (screening and diagnosis) obesity, it has some limitations which the clinicians should be aware of:6,7

  1. Asian-specific BMI and not the WHO Global BMI parameters should be used to assess obesity in South Asians.32,37,38
  2. BMI should not be used as the only method to assess obesity. BMI should be combined with, at minimum, a waist circumference to capture adiposity correctly (Table 4).
    • BMI does not distinguish between muscle weight and fat weight. Though it has high specificity for obesity, it has very low sensitivity for adiposity. Therefore, approximately 50% of individuals with excess fat fail to be classified as overweight/obese.39
    • BMI is unable to catch body fat distribution, which is a marker of metabolic disturbance, cardiovascular risk and linked to T2DM.40–42

Table 4 Parameters Used to Define Obesity in South Asians

Hence, for anthropometry, as discussed above, BMI should be combined with the waist:height ratio (WHR).

Other investigations which can be combined with BMI, if required, are (not usually done):

  1. Dual-energy x-ray absorptiometry (DEXA) or air displacement plethysmography, which accurately assess lean body mass and body fat. DEXA is the gold standard to assess body composition. However, neither of these tests can be used routinely as they are very costly.
  2. Measuring body water using bioelectric impedance is a relatively inexpensive method. It compares body fat mass with fat-free mass. However, large inter-individual variations limit its use.43

Staging of Obesity

The diabesity therapy is guided by the level of obesity. Hence, physicians should be able to identify the stage of obesity and its biochemical parameters. This can be done using well-designed models. The SECURED (Severity of obesity, Expected prognosis, Comorbid conditions, Urgency of control, Risk of complications, Environmental factors, Dysfunction and disability) model (Table 5) lists the parameters that should be considered while developing patient/person-centered care.44 The Edmonton Obesity Staging System (EOSS) (Table 6) or the Cardiometabolic Disease Staging (CMDS) system (Table 7) can help identify the stage of obesity and plan the intervention accordingly.

Table 5 SECURED Model

Table 6 Edmonton Obesity Staging System (EOSS)

Table 7 Cardiometabolic Disease Staging (CMDS)

Recommendations

Physicians can use any of the models in Tables 5, 6 and 7 to assess the stage of obesity and plan the diabesity intervention accordingly.

Overview of Management of Diabesity

Diabesity can be managed by non-pharmacological, pharmacological and surgical interventions. Treating obesity is the primary focus. T2DM remission should aim to be a natural progression of weight control. Pharmacotherapy with anti-obesity medications and glucose-lowering agents should be started where required. Surgical interventions should be considered in patients who cannot be managed through anti-obesity medications and glucose-lowering agents. However, irrespective of pharmacological and surgical approach used, the focus should be on lifestyle management which primarily includes focus on diet and physical exercise. BMI may be used to guide the type of intervention in diabesity (Table 8). However, all treatment decisions should be made based on the patient’s general condition, contraindications for pharmacotherapy/surgery and severity of comorbid conditions.

Table 8 BMI Cut-Offs for Management of Obesity in South Asians

Dietary Concerns in Diabesity

Lifestyle habits need to be changed to prevent and therapeutically cure diabesity, which includes reduced daily calorie intake along with aerobic and strength-building exercises. Many food habits cause obesity/abdominal obesity in South Asians such as (but not limited to):5,11

  1. Excess consumption of refined carbohydrates, sweets and sweetened beverages
  2. Using saturated fats for cooking
  3. Frequent consumption of fried snacks or snacks made with highly saturated fat
  4. Low fruit and vegetable intake resulting in low fiber intake
  5. Increased intake of calorie-dense food

People with obesity often fail to comply with a diet because they prefer highly processed simple sugar containing foods instead of complex/raw carbohydrates. High glycemic index food stimulates serotonin secretion, which, apart from providing a feeling of well being, also increases a craving for carbohydrates.45

Medical Nutrition Therapy

Definition

MNT is the provision of nutritional assessment, advice and follow-up, for prevention and/or management of disease, by a qualified or trained health care provider (HCP). MNT includes dietary, nutritional and culinary advice. It includes both home-made food and medical-grade formulations. As well as diet-related content, MNT also encompasses style of communication and counselling. In the context of diabesity, MNT aims to manage both dysglycemia and adiposity through nutritional intervention.

Indications of Medical Nutrition Therapy

MNT should be integrated into care of all individuals who require glucose control and weight management: either to decrease or increase weight or maintain weight.

MNT is ideal for patients who have:46

  • Cardio-metabolic comorbidities
  • Dietary restrictions due to disease (such as kidney disease)
  • A busy lifestyle and lack of resources for healthy cooking
  • Chewing, swallowing or dextromotor limitations
  • An unwillingness to adhere to a strict diet regime

Classification of Medical Nutrition Therapy

MNT can be classified based on whether it is being given in a therapeutic or preventive setting (Figure 2), whether it is home-made or a commercial preparation (Figure 3) or depending on method of use (Figure 4).46–48

Figure 2 Classification of MNT: therapeutic/preventive. Notes: Data from these studies.46–48

Figure 3 Classification of MNT: home-made/commercial. Notes: Data from these studies.46–48

Figure 4 Classification of MNT: method of use. Notes: Data from these studies.46–48

Goals of Medical Nutrition Therapy

  1. Attain and maintain individualized glycemic, blood pressure, lipid and weight goals.
  2. Delay or prevent complications.

Goals for Diabetes

The ADA recommends the following goals for diabetes:49

  • A1C: 7%
  • Blood pressure: 120/80 to 140/80 mmHg
  • LDL cholesterol: 100 mg/dL
  • HDL cholesterol: 40 mg/dL for men; HDL cholesterol 0.50 mg/dL for women
  • Triglycerides: 150 mg/dL

Goals for Obesity

According to the Position Statement of the Academy of Nutrition and Dietetics (2016), the weight management should be aimed at:50

  • Preventing further weight gain
  • Reducing body weight
    • Short-term goal: 5 to 10% loss, or 0.5 to 1 kg per week
    • Interim goal: Maintenance
    • Long-term goal: Additional weight loss, if desired
  • Maintaining the achieved lower body weight over the long term

Weight management in certain populations (such as eating disorders, pregnancy, receiving chemotherapy) will need to be individualized to their specific needs.50 For example, the goals of MNT in gestational diabetes are to support maternal, placental and fetal metabolic requirements. It is the first step to introduction of a healthy eating pattern in mothers and therefore their children for the rest of their lives.51

Challenges of Providing Medical Nutrition Therapy in South Asia

In the advanced countries, MNT forms an integral part of diabetes and obesity care, is person-centric, and necessary for proper management of the disease as the “only therapy” or as a therapy in addition to pharmacotherapy/surgery.52 However, in South Asian countries like India, MNT is not covered by insurance. Physicians are not sensitized enough to place as much emphasis on MNT as on pharmacotherapy/surgery. Hence, mainstreaming MNT is a challenge in these regions.52

Additionally, most hospital and clinical settings in this region provide pre-printed standardized MNT charts/dietary options/dos and don’ts/list of healthy snacks/macronutrient alternatives etc. There is very little scope for a registered dietician (RD) to make individual specific changes based on medical requirement, psychosocial preference, culinary practices and taste.52

It is therefore important to integrate MNT given by an RD into the primary care of a patient with diabesity with an aim to restrict calories, improve metabolic parameters and achieve weight loss.53,54

Different Types of Diets

Evidence shows that MNT is effective in reducing weight and resolving T2DM.18,19,55,56 However, responses to a different diet varied in participants. Each diet type had its own benefits. In the Look AHEAD trial, the arm with intensive lifestyle intervention incorporated partial liquid meal replacement to achieve dietary goals. Participants in the intensive lifestyle intervention group lost significantly more weight than DSE participants at year 1 and year 4 (net difference, −7.9% and −3.9%, respectively).19

Depending on the calorie intake, a hypocaloric diet ≤1200 kcal/day) can be a low-calorie diet (LCD; 800 to 1200 kcal/day) and a very-low-calorie diet (VLCD; 200–800 kcal/day). If carbohydrate in VLCD is restricted to about 50 g/day, it is known as a very-low-calorie ketogenic diet (VLCKD).57 The RSSDI recommends the low-carbohydrate ketogenic diet over the low-calorie diet.15

In the DIRECT trial, participants randomized to low fat, Mediterranean and low carbohydrate diets lost approximately 2.9 kg, 4.4 kg and 4.7 kg, respectively. The low carbohydrate arm showed a greater decrease in triglyceride levels than the low fat arm. Only the Mediterranean diet could decrease fasting glucose in patients with diabetes. All groups showed a decrease in insulin levels. Though HDL levels increased in all groups, the low carbohydrate group showed a higher increase in HDL than the low fat group.56

In the POUNDS Lost study, weight loss was similar in the low fat/average protein (highest carbohydrate), low fat/high protein, high fat/average protein and high fat/high protein (lowest carbohydrate) arms (2.9 kg vs 3.8 kg, vs 3.9 kg vs 3.5 kg).58 HDL cholesterol increase was greater with the lowest versus highest carbohydrate diet. All diets except the highest carbohydrate increased fasting insulin.

MNT is also effective as a first-line therapy in gestational diabetes mellitus (GDM).51 A sub-analysis of the St Carlos GDM Prevention Study showed that Mediterranean diet (MedDiet)-based MNT in GDM resulted in near-normoglycaemia and pregnancy outcomes were similar to women who did not have diabetes during pregnancy.55

Diet patterns, composition, quantity, advantages and disadvantages of various types of diets are included in Table 9. This is just for guidance, and many dietary patterns may overlap in a patient.

Table 9 Various Types of Diets in Diabesity and Their Advantages and Disadvantages

Step-Wise Integrated Approach for Medical Nutrition Therapy

In their white paper on diabetes, Daly et al (2009) note that MNT provides

more intensive nutrition counselling and a therapy regimen that relies heavily on follow-up and feedback to assist patients with changing their behavior(s)….59

MNT cannot be generalized. It has to be individualized to patient need and involve proper diagnosis, nutritional assessment and counselling. MNT needs to be provided in a step-wise approach after careful assessment of the patient (Figure 5).53,60 MNT advice should be aimed at promoting weight loss without major disruption in a family’s eating practices.60 MNT needs careful monitoring and adherence to achieve the desired outcomes. This can only be achieved through a collaborative effort between the patient, family members, RDs, diabetes educators, treating medical team and culinary scientists.53,54

Figure 5 Step-wise approach for implementation of MNT. Notes:Components of medical nutrition therapy. Data from Kapoor et al.60

MNT is recommended by the ADA, RSSD and Indian Council of Medical Research (ICMR) as part of routine care in diabesity.15,61 The components of MNT recommended by the ADA, RSSD and ICMR are listed in Table 10.15,53,61 Key recommendations for components of MNT were not available from other South Asian regions. Hence, the experts involved in CoMeND studied these recommendations to formulate their own recommendations for South Asia. Key features are listed in Table 10.

Table 10 Components of MNT: Comparative Analysis of Recommendations by the ADA, RSSDI, ICMR and CoMeND15,53,61

Recommendations for Medical Nutrition Therapy

These recommendations can be divided into three main groups.

Group A: General Dietary Recommendations

  1. Food portions should be reduced but not cut down drastically. The plate method can be used to control portion size of different major food groups (Figure 6).
  2. The diet of a patient with diabesity in South Asia should be planned carefully, keeping in mind the country and region specific influence on culinary diversity, lifestyle and economic condition.11,62
  3. Healthy dietary patterns should always be recommended. Diet education should be a part of patient counselling.17,63
  4. A hypocaloric diet should be advised and individualized to patient’s need.5,29 Appendix I gives the approximate calorific values of commonly cooked food items. This can serve as a guide for calorie planning.
  5. Patients should be encouraged to maintain food diaries. These help understand food patterns, emotional eating patterns, and patients’ perceptions of and behaviors towards food.17,63

Figure 6 Plate method for meal planning.

Group B: Nutrient and Care

  1. Carbohydrate and saturated fats should be reduced (Table 10).
  2. Correct oils (PUFA and MUFA) and cooking methods (steaming, baking, shallow-fat frying, low fat cooking etc) should be advised.11
  3. Unless contraindicated (eg as in kidney disease), normal protein diets or supplements should be recommended as most patients in the South Asian region consume much less protein than their RDA.
  4. The goals of MNT should be monitored regularly. The frequency of monitoring may need to be individualized based on patient’s acceptance and adherence to MNT.
  5. Any eating disorders identified should be treated as a priority through proper education, counselling and pharmacotherapy.17,63

Group C: Medical Nutrition Therapy

  1. MNT should be individualized based on the Degustation Pentad (Figure 7) proposed by Dr. Kalra and colleagues. This pentad is based on a Vietnamese culinary philosophy. It suggests that an individual’s meals should appeal to all five human senses (vision, smell, taste, touch, and hearing).54,64
  2. MNT should be designed such that it incorporates the:
    • Biomedical triplet of diet to provide the right macro-nutrient balance (protein energy) and adequate micronutrients. MNT should be medically/metabolically appropriate and yet low in glycemic index.54
    • Comorbidities like dyslipidaemia, renal disease, coeliac disease, hyperuricaemia etc.54
  3. MNT needs to follow the seven As of dietary choice in order to promote adherence in patients. Thus, it needs to be Appropriate and Accurate for the patient’s needs, easily Absorbed, Affordable, easily Accessible, Acceptable (conform with taste preferences of the individual; have the right aroma) and Attractive (visually appealing) to that individual (Figure 8).53,54
    • MNT should be affordable; crafted with locally available food items; conform with local customs, beliefs and taboos; easy to prepare; provide enough alternatives; and consider religious and social practices of the community for which it is being designed.54
  4. Formula MNT can be a:
    • Meal replacement plan for patients who have a busy lifestyle or who are not willing to adhere to a strict diet regime.
    • Meal replacement for individuals who have limited access to healthy cooking or who have difficulty in calculating calories.
    • Meal supplement for individuals involved in exertion activities or those having chewing, swallowing or dextromotor limitations.
  5. MNT should be in concordance with pharmacotherapy, so13
    • A 3 + 3 meal pattern is recommended with
      • Intensive insulin therapy (basal bolus)
      • Sulfonylureas
    • Regular snacks should be suggested for individuals
      • On pre-mixed insulin
      • On human insulin
      • Having a lifestyle involving exertional physical activity.

Figure 7 The culinary pentad/“Degustation Pentad”. Notes: Data from these studies.54,64

Figure 8 The seven A of MNT. Notes: Data from these studies.53,54

Physical Activity and Lifestyle Interventions

Lifestyle behavior therapies are successful in reducing weight and resolving T2DM. However, the level of benefit seen varies with BMI level. In the Look AHEAD trial, patients in the bottom and top 25% lost <3% of their body weight and 12 kg at eight years, respectively. Intensive lifestyle intervention produced better results than diabetes support and education.65

Physical activity can cause modest weight reduction. Its main importance during weight management is that it helps in preserving fat-free mass and maintaining weight. Physical activity promotes cardio-respiratory fitness and reduces cardiovascular risk.17

Recommendations17,63

  1. Physical activity counselling should be an integral part of obesity management. This should include advice on building physical activity in everyday life and a supervised structured exercise program under the guidance of an expert.
  2. Exercise prescription must be individualized, keeping in mind the patient’s health and fitness status and ability to exercise.
  3. Structured exercise levels should be gradually stepped up to levels that are safe for the patient.
  4. A higher volume of physical activity is required for weight maintenance than is recommended for the general population for health maintenance.
  5. Adequate protein intake should be ensured to build muscle mass during strength training.

Managing Right Food Intake in a Setting of Abundance

Urban areas in South Asia have an abundance of food. The urban population therefore needs to make the right choices in their diet when they are spoilt for choice. Many of the strategies covered in this section, however, pose challenges in lower middle income South Asian countries.

Recommendations

  1. Patient education and self-restraint can help people make the right food choices. Health education and moderation in food intake should be started at school level to ensure development of healthy lifestyles and food practices for life.66
  2. Restricting access to unhealthy food types may restrict their purchase and consumption and thus may help reduce weight.
  3. Healthy food alternatives should be easily available at home and in the workplace.
  4. It may be possible to curb obesity by providing more places for exercising and building exercise as a culture.
  5. Encouraging use of smartphone apps which provide nutrition and/or exercise and fitness guidance. These apps have comprehensive nutrition databases that tell a user the nutritional content of an item after scanning the barcode, allow them to search for healthy options from restaurant menus and help them recognize food items on a plate. Smartphone sensors use machine learning and symbolic reasoning to recognize and quantify lifestyle activities of patients with diabesity and help them make more informed activity choices if necessary.
  6. Proper pricing and promotion strategies need to be implemented to reduce intake of unhealthy food. These strategies include (but are not limited to)11,66–70
    1. Establishing farmers’ markets in all neighborhoods.
    2. Making subsidized fresh fruits and cooked vegetables available in schools.
    3. Increasing prices of high-fat and high-sugar foods, especially in school and office cafeterias and neighborhoods (one option is to increase taxes on these). Additionally, low fat/low sugar healthy foods can be made available at affordable prices.
    4. Revisiting marketing strategies involving healthy foods.

Monitoring

Patient adherence to diet and motivation to stay on diet wanes over time if the dietary recommendations are not monitored over time.71 According to the Academy of Nutrition and Dietetics, the parameters listed in Table 11 should be assessed and monitored for an effective weight management.

Table 11 What to Assess and Monitor in Patients with Diabesity

Counselling and Motivation

Need for Counselling and Motivation

Stress is associated with overeating, which increases weight. Obesity in turn adds further stress due to development of other comorbidities and because of stigmatization. A study from Southern India on morbidly obese individuals suggested that about 30% of individuals attending an obesity clinic had psychological problems.72 This leads to a vicious cycle and diabesity management fails. Cognitive behavior therapy (CBT) can help an individual recognize and change behaviors associated with stress and overeating. It can teach an individual to manage stress well.17

Recommendations for Counselling

MNT and lifestyle interventions are likely to fail if patients are not kept sufficiently motivated throughout life. Hence, it is very important for physicians to understand their patients well and keep them motivated.73 The approaches mentioned in Table 12 can be used to guide counselling. However, help from a trained psychologist should be used if the physician feels that the patient needs more rigorous counselling and follow-up to follow recommended diet and lifestyle changes.

  1. Diet, exercise and behavioral therapy is recommended with or without drug/surgical therapy (as applicable) and in both preventive and therapeutic settings.
  2. HCPs should focus on patient’s QOL and how diabesity is affecting their QOL.24
  3. Addressing psychological aspects of diabesity care will help in better adherence to therapy.
  4. The patient should be given the right to make decisions regarding treatment. The HCP should outline all treatment choices, their benefits and side-effects, to the best of his/her knowledge. However, the physician should guide the treatment decision in the right direction, especially in a low literacy level patient, and where the patient’s decision may cause dire consequences for health.25
  5. Patient education should be built into diabesity care. This should be reinforced at diagnosis, then annually, at the time of complications/change in treatment and when there is a change in care.13

Table 12 ABCDE Approach to Counselling in Diabesity

Way Forward in Diabesity Management in South Asia

Personalized Medicine in Diabesity: Role of Gut Microbes and Genes

Diabesity is a chronic disease influenced by the patient’s nutrient intake, food and beverage consumption, genetic background, microbiome (microbes colonizing in human beings and their genes), and omic profiles including metabolome.74–76

The gut microbiota in a patient with diabesity causes many pathological changes in energy harvest and in the modulation of free fatty acids (mainly butyrate), bile acids, lipopolysaccharides and toll-like receptors. Many other changes have been implicated in diabesity. In a nutshell, these changes result in changes in inflammation, insulin signalling and incretin production and therefore contribute to the development of diabesity.74,75

Gut microbiota, host (patient with diabesity) and diet form an important trialogue in diabesity.74 Gut microbiota change with diet, disease, medication and other host factors. Therefore, gut microbiota in patients with diabesity differ from those in healthy individuals. Of these factors, the patient’s diet plays the most important role (Figure 9).

Figure 9 Diet is the main factor affecting composition of gut microbiota.

Many genes modify the response to diet and their study can open the path to personalized medicine in diabesity.57,77,78 The POUNDS Lost study was conducted to increase understanding of this area. The study randomized 811 individuals to one of four diets: (20% vs 40% fat and 15% vs 25% protein) to understand the genetic factors that modulate dietary response.79,80

Personalized medicine also combines many environmental factors to predict response to diet. A study showed that an algorithm integrating anthropometrics, blood parameters, dietary habits, gut microbiota and physical activity could accurately predict an individual’s postprandial glycemic response to real-life meals (Figure 10).81,82

Figure 10 Different aspects of personalized nutrition.

Current research in precision and/or personalized nutrition shows the benefits of individually tailoring dietary interventions (including therapeutic intervention to trigger gut microbiota with prebiotics, probiotics and synbiotics).74 However, this is a new and upcoming field. Further research, especially in the form of large Phase 3 trials, are required to understand the exact benefits of personalized medicine in diabesity.

Patient/Person-Centered Care

Since South Asia is a developing region, it is now time to introduce the Western concept of person-centered or patient-centered care. This means involving patients in their disease care, giving them the right to make treatment decisions, educating them about their disease and taking care of their psychological needs.13,24–26 The Second Diabetes Attitudes, Wishes and Needs (DAWN2) study carried out in seventeen nations, including India, shows that 26.7% of HCPs in India fail to ask their patients how diabetes affects their lives. In contrast, about 55% of patients in India reported that their HCPs do not ask them about their QOL with diabetes.24 Hence, concentrated efforts should be made to integrate person/patient-centered care into the diabesity care algorithm.

Acknowledgment

All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this manuscript, take responsibility for the integrity of the work, and have given final approval for the version to be published. The authors thank Dr. Chetan Mehndiratta, Mr. Tanmay Agrawal of Signutra Inc for execution of the study, and Dr. Kokil Mathur and Dr. Punit Srivastava of Mediception Science Pvt Ltd (www.mediception.com) for providing medical writing support in the preparation of this manuscript, funded by Signutra Inc. India.

Disclosure

The authors report no conflicts of interest in this work.

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