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.
Diabetes &
Primary Care
Issue:
Vol:23 | No:06
Conference over coffee: Obesity, low-carb diets and NAFLD
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.
● Actively manage coexisting diabetes, hypertension and alcohol excess.
● Strongly encourage and facilitate weight loss where possible.
● Consider referral if:
● 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.
Updated guidance from the PCDS and ABCD: Managing the national GLP-1 RA shortage
Diabetes Distilled: Fib-4 – A diagnostic and prognostic marker for liver and cardiovascular events and mortality
At a glance factsheet: Tirzepatide for management of type 2 diabetes
Editorial: Lipid management, tirzepatide and hybrid closed-loop: What does new NICE guidance recommend?
Case report: Pancreatic cancer – assessing diabetes in a thin elderly person
Prescribing pearls: A guide to DPP-4 inhibitors (gliptins)
How to conduct an extended review for people with early-onset type 2 diabetes
Advice on selecting alternative glucose-lowering therapies when GLP-1 RAs used in the management of type 2 diabetes in adults are unavailable.
22 Mar 2024
Should sequential Fib-4 testing now be made part of ongoing care in people with obesity and/or type 2 diabetes?
18 Mar 2024
Indications, benefits and side effects of tirzepatide, plus tips for prescribing.
6 Mar 2024
With a raft of newly published NICE guidance, Jane Diggle discusses the implications for practice in primary care.
6 Mar 2024