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Conference over coffee: Obesity, low-carb diets and NAFLD

The 14th Scottish Conference of the Primary Care Diabetes Society was held virtually on 26 October 2021. In this short report, we deliver the key messages from the three plenary sessions at the conference. Readers are encouraged to view the on-demand sessions and masterclasses (available here) at their leisure; however, in the meantime it is hoped that these short, sharp summaries will provide you with useful and practical points – all in the time it takes to make a cup of coffee!

Obesity

Rachel Pryke

GP, Redditch, and RCGP Clinical Advisor on Obesity and Nutrition

 

Take-home message: Individualise diet advice – one eating pattern does not suit everyone for weight loss.

 

What can primary care teams do?

● Get trained: Try SCOPE e-learning: https://www.scope-elearning.org

● Get asking: “How do you feel about your weight?”, or “Is it OK if I ask about your weight?”

● Get scales: Up to 200 kg as standard.

● Get weighing: Calculate and code BMI.

● Get referring: Know your local obesity pathway. Contact and lobby locally if services are poor.

● Get going: Encourage physical activity to benefit health independently of, and to support, weight loss.

 

Diagnosis and management of non-alcoholic fatty liver disease (NAFLD)

Kevin Fernando

GP partner and GPwSI Diabetes and Medical Education, Berwick

 

Interpreting AST:ALT ratio

● Ratio ≤1.0 suggests NAFLD with low risk of progression.

● Ratio >1.0 suggests more serious liver disease and higher risk of progression.

● Ratio >2.0 strongly suggestive of alcoholic liver disease.

 

What can primary care do to lower risk of advanced fibrosis?

● Assess cardiovascular risk using QRisk3-2018 (https://qrisk.org/three), and consider a statin.

  • Only stop statin if ALT doubles within 3 months of starting.

 

● Actively manage coexisting diabetes, hypertension and alcohol excess.

● Strongly encourage and facilitate weight loss where possible.

● Consider referral if:

  • AST:ALT ratio >1.
  • LFTs >3× normal upper limit.
  • Symptoms and signs progression of liver disease.
  • Any features of atypical disease.

 

● Reassess at 2–5 years depending on clinical risk.

 

To go low-carb or not?

Nicola Guess

Dietitian and Research Fellow, King’s College London

● Start by understanding what people are eating and their goal(s). Check whether the previous day was typical. Use 24-hour recall to find out what they ate and drank the day before the consultation.

● Understand what the person knows about nutrition so you can pitch the discussion at the right level.

● 24-hour recall may flag up one or two key changes which would be beneficial. Explore whether these are acceptable.

● For sustainable changes to eating habits, people have to like the food they are eating. They also need to be able to prepare and cook or purchase the foods included.

● Amino acids in protein have been shown to be insulinogenic; inclusion of protein at each meal (e.g. 20% of daily calories) may improve first-phase insulin response and reduce glucose output from the liver, both of which are abnormal in people with type 2 diabetes.

● Much of the evidence base on low- and very-low-carbohydrate diets is unhelpful as there is huge variation in definitions and in what was actually eaten by participants in the studies. Weight loss also confounds results.

 

Further resources

How to diagnose and manage NAFLD in diabetes: Quick reference guide to the diagnosis and management of this challenging condition.

How to improve carbohydrate awareness: All the background information and practical tips needed to discuss carbohydrates with patients.

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