Resources

  1. Abutair et al. Nutrition Journal (2016) 15:86  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5062871/pdf/12937_2016_Article_207.pdf



Transcript

Dr. Frank Domino:

Dan is scheduled today for a follow up of his, type 2 diabetes hypertension, in hyperlipidemia. He was initially happy with his improvements in weight and A1c after starting Metformin and making some dietary changes. He promises you that he eats really healthy. But over the last few months he's found he could no longer lose weight, or get his A1C to go down. Your history reveals he's eating large portions and often eats quickly, sometimes in front of the television. What can you do to help him? Hi, this is Frank Domino, Professor in the Department of Family Medicine and Community Health at the University of Massachusetts Medical School, and joining me to discuss type 2 diabetes and weight loss is Jill Terrien, Nurse Practitioner, and Director of the NP programs in the Graduate School of Nursing at the University of Massachusetts Medical School. Hi Jill.

Jill Terrien:

Hi Frank.

Dr. Domino:

So Dan and his weight.

Susan Feeney:

Yeah, so this is, I would say, is this a typical patient, Frank?

Dr. Domino:

Absolutely. How about for you?

Jill Terrien:

Yes, it definitely can be. And I'm really interested in hearing what you have to add to

his... He sounds like he's really trying to do a good job.

Dr. Domino:

Well, he's got a... He's got a number of hurdles so he eats large meals, he tends to eat

fast, he doesn't pay attention and he's got quite a few challenges to try to get things under control, and I think he's pretty common. We know that overweight and obese folks are at higher risk for type two diabetes and all their subsequent complications and medication alone can only mitigate that risk a small amount. We have to help people change their behavior. And Dan's definitely one who's been trying, but it seems like we have to find some new ways to help him.

Jill Terrien:

So yeah, you mentioned his challenges. What are you gonna start with at this visit?

Dr. Domino:

Well, I think the first thing you need to do is look at how he's eating and see what might be available to address it. I think with most patients who possibly overeat, the first thing I tend to focus on is helping them be mindful of their eating habits. He says he's eating healthy, but when you get down to quantify things with him, he's eating very large portions. And what he defines as healthy or what other things tell him are healthy may not be healthy for him. They're certainly not gonna help him lose weight. So I think that's the first thing I wanna do is talk about where he eats, when he eats, how he eats. Portion control. There are a variety of ways to address portion control. One is to help him get a smaller plate and just put one serving of food on it, not stack it as high as he can and try to just focus on that. Try to keep half of his calories from coming from carbohydrates and no more. And tell him to eat slowly. Try to have him put down his fork and spoon after each bite, not sit in front of the TV, his laptop, his phone, but to really savor the food that he's eating. The other option is, since he eats large portions, is he probably eats fast because he's not paying attention and it takes a while for him to feel full.

And one way to address this is to try to find ways to increase fiber, before he eats. This will help him feel full quicker and there's a variety of other theories about the role of fiber and weight loss that are very positive. So I think those two key things are most important in helping him lose weight. Be more mindful of how he eats to help him have better portion control, better ability to push away his plate and introduce fiber before he eats.

Jill Terrien:

Well, that all sounds great, and it sounds like of a lot of good things for him to take away from the visit today. I particularly like the fact of the smaller plate, but I also like when you talk about two-thirds not being the carbohydrate intake, right? So sometimes I have patients visualize their plate and say, "What does it look like?" And it should have the vegetables and the fiber and everything on two-thirds of the plate.

Dr. Domino:

That's a great idea.

Jill Terrien:

And the protein. I'm interested in the fiber and also his large portion sizes. And I'm wondering how many meals does he eat a day? 'Cause maybe you can also break those up into six smaller meals.

Dr. Domino:

I think it's very common for people who are trying to lose weight, to "skip breakfast". They'll snack throughout the morning. They'll think their having a salad for lunch will be good, but they'll get no protein and then they'll snack throughout the afternoon and then eat a large portion right before bed time, all the opposite things. So, you're 100%, right. We need to help him plan out his meals much better so that he's getting regular exposure to protein, fat, and carbohydrate and six small meals is a fantastic way to do it.

Jill Terrien:

So tell me more about the fiber. I mean, when we think about fiber, some patients, we have to talk to them about constipation, as well. Right? That's one of... One of the side effects, especially if they're not taking enough fluid. So tell us how you can introduce fiber and help Dan.

Dr. Domino:

So I was discussing Dan with a dietitian friend, and she told me about this randomized control trial, where they had folks consume 10 grams of psyllium fiber. So psyllium is a soluble fiber, it comes from the plantago plant and it comes as psyllium husks, or psyllium powder. And in this study, they took obese patients, and they had them in the intervention group, they had them take seven grams of psyllium before lunch and 3 1/2 grams psyllium before dinner. Each with a large glass of water. And they just followed them forward over eight weeks time. And they gave them a little bit of dietary counseling saying, "No more than 55% of your calories should come from carbohydrate. Get adequate fat and adequate protein." That was it, they did not focus at all on the dietary changes. And what they found is that at eight weeks, the average weight loss was around 6 1/2 pounds. Not only that, they decreased their BMI, they decreased their waist circumference, and they decreased the metabolic parameters that we follow with diabetes, including A1C levels, insulin level, C-peptide levels, and HOMA levels.

So this was a very simple, real world intervention that I love, because there was very little risk. It allowed people to pretty much continue with their dietary patterns as long as they took the psyllium beforehand and drank enough water so they didn't get constipated from it. And it provided a good outcome. So I like this intervention, and I think it's something that most patients, especially those who overeat can really benefit from.

Jill Terrien:

That sounds great. So how would they go about getting psyllium?

Dr. Domino:

So like I said, psyllium comes in two forms: It comes in the husk form and the powder form. The powder form is more dense, and so you can get it as a powder and very commonly available brand named stool softeners mostly contain psyllium. You've seen them on the shelves, and heard their advertisements on television. But that normally requires two, three, four teaspoons of this powder a day which many people don't find palatable. The other way they come is in capsule form and you might have to... To get this amount of fiber, you might have to have six or 10 capsules with a large glass of water, but it's much easier to take. People find it much more acceptable and doesn't require drinking anything gritty, or artificially flavored, and they're very, very reasonable. You can buy 200 of them for $7 at most local pharmacies.

So I would suggest, if he wanted to go this route, I would suggest him buying some psyllium powder capsules, and convert it so he's getting around five to seven grams before his mid-day meal and another three to four before his evening meal, drink a great deal of water and remind them of the side effects. The side effects tend to be constipation if he's not drinking adequate water and it can cause gas. And so you have to kinda warn them that they need to not jump to this total, but gradually increase over time.

Jill Terrien:

That's great Frank. And it sounds like it's an intervention that could possibly have a very great benefit for Dan overall. So you've given him some great advice today and probably something... You have him engaged, he's telling you he's doing all these things, so you're tweaking what he's doing and the outcome could be of great benefit to him.

Dr. Domino:

I often tell people who are trying to lose weight. That it took them a while to gain a great deal of weight so it's going to take a great deal of time to try to undo some of that damage. And this is just one more tool, plus the mindfulness that can really help.

Jill Terrien:

Thank you Frank.

Dr. Domino:

Thanks Jill.