“Person-centred care is about developing a plan of care with people that fits with what that person is ready, willing and able to action. It means that the person is an equal partner in the planning of care and that his or her opinions are important and are respected. That doesn’t mean that ‘what the person says, goes’, but it does mean that we have to take into consideration and act on what people want when we plan and deliver their care.”(1 - see references below)
I read in Dietetics Today media releases of a dietitian advising that meal replacement shakes are not recommended for weight management. The article stated that using meal replacements promoted a “diet mindset” which was usually a short-term approach, that making smaller long-term changes to the whole diet would work better long term, but that it could be a useful tool to kick start a plan.
These points are all valid and, of course, this article was a soundbite of general advice not intended for an individual. However, this made me think about the many times I have seen dietitians advising patients referred for weight loss that:
1. Research shows the Eatwell Guide is the best way to follow a healthy diet to lose weight and
2. Other dietary approaches for weight loss are not recommended.
That same week I overheard a colleague speaking to a patient recently diagnosed with cancer. My colleague was calling to discuss the recommended diet for her condition which was low fibre to avoid bowel obstruction and to avoid losing weight to make sure she was able to withstand any treatment side effects. The patient was already following a ketogenic diet with a focus on low glycaemic index foods and wholegrains. This was about as far removed from the diet recommended as it was possible to be. My colleague was clearly challenged by this. She explained the diet recommended and the rationale for this but then concluded: “However, it is my job to support you whatever you choose to do.”
In both these scenarios the patient’s agenda is different from the dietitian’s. The dietitian is concerned about patients following eating plans which are not based on the best research evidence. The outcomes are very different because in one scenario the dietitian responds to the needs of the patient and in the other the focus is on the research evidence.
In the first example a patient looking for ways to lose weight might consider a wide range of options and might ask the dietitian about using meal replacement shakes. Changing your diet to lose weight is difficult and the dietitian’s role is to explore all available options before agreeing a plan. If the dietitian advises this patient that the only recommended way to lose weight is by following the Eatwell Guide the risk is that:
- They will try meal replacements anyway and
- The patient feels that their views have not been listened to. The dietitian has lost the chance to build a rapport which would encourage them to return for follow-up.
- Without support this patient may lose weight but without developing skills to keep weight off long-term may end up regaining weight and feeling demoralised and demotivated.
In the second example the patient was following a diet very different from that recommended for her condition, a diet which would put her at risk of bowel obstruction if her cancer spread. It was likely to be low energy density which would increase the chances of weight loss if appetite reduced at any point. Her dietary preferences might mean that she would be reluctant to fortify her food or to take any oral nutritional supplements should these be recommended in future.
However, in this initial consultation the dietitian had listened to the patient’s preferences and respected these despite being uncomfortable with them. She had used a non-judgemental approach to explain the rationale for the diet recommended so that the patient could make an informed choice. Finally and most importantly she had stated her willingness to support this patient regardless of her choice. This means that:
- The patient feels her views have been heard and respected. She has developed a rapport with the dietitian which will encourage her to seek support through her cancer journey if she has concerns
- She has been given information to consider about what diet is recommended and why
- The patient may decide to make some changes to her preferred diet to reduce fibre, because she trusts the dietitian and the advice she provided.
In the Specialist Weight Management Clinic at Leicestershire Partnership Trust, patients with severe obesity can choose from a wide range of dietary options. This increases the chances of arriving at a plan the patient is happy with, one that suits their lifestyle and which they can follow most of the time.
We start by calculating energy requirements using the Mifflin St-Jeour equation and often give patients one plan based on 600kcals less and another based on 1,000 kcals less than requirements. Many patients find it easier to adhere to a low calorie eating plan on some days and need the flexibility to be able to eat more on other days.
We ask what types of eating plan have worked well for them in the past and which they would like to try. Regular meals and snacks are encouraged. For some patients the Eatwell guide is used to devise a regular eating plan which gives guidance on portion sizes recommended. Patients are encouraged to decide what they want to eat and use the plan to help them serve the right amounts.
For example, a main meal for a 2500 kcal plan would consist of two protein portions, three starchy food portions and three vegetable or salad portions. Patients planning to eat spaghetti bolognese would serve three portions of spaghetti (150g cooked weight) and two portions minced meat (160g cooked weight).
Increasing numbers of patients are interested in a low carbohydrate diet. This may be suitable for people with poorly controlled type 2 diabetes and those on short acting insulin. Using the traditional Eatwell Guide approach results in advice to eat large amounts of starchy foods for higher energy prescriptions (11 x 80 kcal portions for 2,500 kcals daily).
In our experience, patients struggle to manage these amounts. A modified approach in which starchy food portions are reduced and protein portions are increased is often managed better. Using the 2,500 kcal example, starch could be reduced from 11 to seven portions daily and protein (140 kcal portions) increased from four to six portions daily, with other food groups remaining as per the Eatwell Guide. For some people who prefer to follow a much lower carbohydrate diet we reduce carbohydrate portions down to three daily (providing approximately 130g carbohydrate daily which is the definition of a low carbohydrate diet.)
The traditional energy prescription approach is difficult for some people to follow. We have developed a simpler approach to following a lower carbohydrate diet which can work well for energy requirements of 1800 kcals and below. This involves patients choosing 4-6 x 250kcal meal exchanges daily plus 1-3 x 100 kcal snacks.
Some people are interested in trying meal replacement shakes. Many people are familiar with the traditional approach of using a shake to replace breakfast and lunch and eating a healthy meal at night. In our experience patients usually eat more as the day goes on and their evening meal is the largest (“I’ve been good all day so I can eat as much as I want for my main meal”). There may be little scope to reduce calories by exchanging breakfast and lunch for a shake.
However, shakes may be useful to:
1. Build the habit of eating breakfast and/or lunch for patients who do not eat regular meals
2. Replace an evening meal two or three times a week.
This can be followed by a scheduled healthy snack two-to-three hours later to avoid feeling hungry by bedtime. This approach can be used to cut overall calories eaten across the week but with a lower impact than replacing 14 meals weekly.
Some people are interested in an intermittent fasting approach. A modified version of this using the 250 kcal meal exchange approach above where patients eat fewer calories during the week to allow them to eat more calories at the weekend can suit some people who are very busy at work.
A small number of people are interested in a low calorie liquid diet. We offer patients a 1,000 kcal regime based on four shakes daily with extra vegetables, similar to that used in the Direct study. Most patients have not followed this exactly but it has been useful to demonstrate in a small number of patients with severe insulin resistance that sometimes weight loss is not achieved even on 1000 kcals daily. These patients have gone on to work towards bariatric surgery.
So, in summary, next time a patient asks, “Could I try shakes/cutting out carbs to help me lose weight?” the answer could be: “Let’s see how we can make that work for you.”
2 Lean, M. E.J. et al. (2019) Durability of a primary care-led weight management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trial. Lancet Diabetes and Endocrinology, 7(5), pp. 344-355. (doi:10.1016/S2213-8587(19)30068-3)