'How we start' a tailored nutrition plan matters

Patient-centered strategies and a teamwork approach with registered dieticians may benefit the creation of tailored dietary interventions for treating obesity, said a speaker at the Obesity Medicine Association Spring Conference.

“The treatment of obesity is not simple, and we need a whole village to help support our patients through this journey ... you can’t do it yourself,” Ethan Lazarus, MD, FOMA, owner of the Clinical Nutrition Center, president of the Obesity Medicine Association and delegate of the AMA, said during the presentation.

Before deciding on a nutrition plan, Erin Winchester, RDN, a dietitian nutritionist at the Clinical Nutrition Center and a professional chef at the Cordon Bleu Institute, asks the patient what change they think they could implement reasonably, easily and consistently for a long period of time. Patients and providers should keep in mind that the nutrition plan will vary as time goes on and differs from patient to patient.

“You are not marrying this diet,” Winchester said. “We can always make changes.”

There are several established diet plans, such as the Mediterranean diet, ketogenic diet, paleo diet and intermittent fasting. However, there is no need to prescribe just one diet approach. A combination of several can be pursued depending on what works best for the patient, according to Winchester.

Lazarus and Winchester described the four streamlined food plans they use at the Clinical Nutrition Center: individualized, advanced, modified fast and meal replacement. The plans can be modified for each patient.

Individualized program

The individualized program is the most flexible and involves an “exchange” style nutritional intervention. This program may be more suitable for patients who want to make small changes to their diet, according to Winchester. It emphasizes portions from different food groups. The number of calories consumed with this plan is typically greater than 1,200 per day.

Advanced program

The advanced program is somewhat more restrictive than the individualized program, Winchester said. It involves lower carbohydrate consumption (70 g to 100 g per day), protein (80 g to 120 g per day), non-starchy vegetables, fruits and dairy with no other starches, limited fat and an individualized consumption goal that is typically around 1,200 calories per day.

Modified fast program

A modified fast program emphasizes protein (80 g to 120 g per day). Meanwhile, it greatly decreases carbohydrate consumption to less than 50 g per day. The program excludes most dairy and fruit products and often uses a partial meal replacement. In total, this plan involves 800 to 1,000 calories per day for most patients.

Meal replacement program

This program employs meal replacements designed to meet 100% of the recommended dietary allowances for micronutrients. This does not include protein shakes, Winchester said. Usually, the program sets a calorie goal of 800 to 1,500 per day based on the patient’s BMI. Most often, patients have a solid meal for dinner of lean protein and non-starchy vegetables, with meal replacements consumed at breakfast and lunch.

Patients on a more intense food plan, such as the full meal replacement program, will eventually want to transition back to more conventional foods, according to Winchester. Food variety should be increased in a stepwise fashion while monitoring total daily calories. Treatment, support, accountability and regular exercise are important to continue while increasing food variety in order to maintain weight loss.

Teamwork approach

At the Clinical Nutrition Center, Lazarus typically requires patients to have a pre-visit with a registered dietician team member prior to any clinical visits with him.

“By the time they come to see me ... they have a pretty good idea what they are getting into, and this isn’t all new information,” Lazarus said.

The more intense the treatment plan, the more weight loss the patient will achieve, according to Lazarus. Yet, the lesser intensity plans allow for more food variety for patients to choose from. During a patient’s weight loss journey, more intense food plans can be laddered on, in addition to medication, to achieve the patient’s desired weight loss goal.

However, “how we start matters,” Lazarus said. Discussing goals with patients can impact which program is implemented first.

In addition, longer visits (30 minutes or more per visit instead of 15 minutes), have enabled Lazarus to “actually treat” patients instead of simply prescribing medication. Frequent communication can be conducted via telehealth and in person.

An in-office registered dietician is not necessarily required to create an effective nutrition plan, Lazarus said. Patients can be monitored with other skilled team members, such as nutritionists, social workers or nurses, in addition to out-of-office referrals. Typically, patients visit the Clinical Nutrition Center in a 3:1 ratio: three visits with a registered dietician and one visit with a physician for medical monitoring. These visits can be spaced out as the patient’s treatment plan progresses.

“You can medically manage your patients with whatever resources you have,” Lazarus said.