Nutritional Therapy Approach and Case Study
Struggling to Control Weight
The fol owing information is for GPs only. It is not intended for use by the general public. It is not intended to promote the services of any nutritional therapist but is provided for GPs to better understand how a nutritional therapist may work. Nutritional therapy is recognised as a complementary medicine. In the case of an individual feeling tired too often, that individual should first visit their GP and undertake any GP recommended tests to exclude any serious medical issues. Practitioners never recommend nutritional therapy as a replacement for medical advice and always refer any client with ‘red flag' signs or symptoms to their Once the GP has excluded common organic causes of weight gain including side effects of prescription medication and hypothyroidism, a nutritional therapist wil take a full case history including family history, past and current symptoms; review a food and lifestyle diary and take a holistic approach, considering the interrelationship of co-morbidities. They may consider whether some the fol owing may be contributory factors to an individual’s health status: • Suboptimal diet including high intake of refined carbohydrates, stimulants, processed foods. • Lack of satiety and increased appetite • Dysglycaemia (blood sugar imbalance) • Lifestyle factors such as stressors, sleep and lack of activity. Case Studies
Weight Loss Case Study 1. Female, Baseline BMI: 38.3
Sara Kirkham BSc(Hons) Nutritional Medicine, MBANT Mrs J weighed 15 stones, so with her height of 5 feet 3 inches her body mass index was 38.3 and she was classified as obese. She had repeatedly tried various diets but even if she had initial y lost weight on a diet, she regained it. She couldn’t understand why she was overweight as she didn’t feel like she ate very much. She didn’t do any exercise and had a sedentary job in an office. In addition to being overweight, Mrs J felt very lethargic and felt that her weight was getting her down. She had been to the doctor to check her thyroid function as she thought she may have an underactive thyroid, but thyroid tests showed normal levels of thyroid hormones. The nutritional therapist asked Mrs J to complete a 7 day food diary in order to assess the foods she was eating, and to consider the portion sizes of meals eaten. Mrs J’s diet was found to be high in reduced calorie high sugar diet products and refined carbohydrates, and portions were large. Regular consumption of reduced calorie foods high in sugars and refined carbohydrates was prompting more regular eating and she was often choosing foods with a high glycaemic index in order to increase blood glucose levels. She was also snacking on high fat, high calorie foods. Mrs J was provided with a healthy balanced diet. The intake of sugar was reduced, and meals were based upon low glycaemic carbohydrates in conjunction with protein foods. She was given an eating plan based upon meals that were high in low energy density foods such as non-starch polysaccharides (vegetables) as these would help to provide reasonable-sized portions that provided fewer calories. The protein serving with each of these meals would provide the satiety to help keep her sustained. A goal to incorporate activity into her lifestyle was agreed, by completing 200 minutes of cardiovascular exercise per week, such as walking. A weight loss goal to reduce her body weight by approximately 5% over the next 6 weeks was agreed with Mrs J. 5% of her starting body weight was 10.5lbs. By fol owing the eating plan and increasing her energy expenditure, Mrs J was expected to be able to create a calorie deficit that wil enable a loss of 1.5lbs weekly (equivalent to 5250 calories). Further options
If dietary adjustment with enhanced caloric expenditure do not appear to be reducing weight, or if the client is struggling to control cravings for refined carbohydrate foods, a further number of diet and/or supplement protocols may be considered. A supplement containing chromium may be considered. Chromium helps with the formation of Glucose Tolerance Factor to increase the efficacy of insulin, hence moderating insulin resistance. (Evans GW and Pouchnik DJ, 1993, Journal of Inorganic Biochemistry, 49, 177-87). Adding spices known to have anti-hyperglycaemic properties can also help. For example, adding cinnamon to fruit, porridge or cinnamon can help to slow down the absorption of glucose and reduce post-prandial blood glucose levels. (Kirkham et al, 2009, Diabetes, Obesity and Metabolism, Fol ow up appointments/Next steps
Clients require differing levels of support to make any dietary or lifestyle adaptations. Some opt for weekly appointments, some are able to stay on track and achieve weight loss goals with monthly or 6 weekly appointments. The regularity of appointments should be based on each individual, although a weekly weight loss goal should always be provided to help keep clients on track. This client chose weekly appointments. As such, the 6 week weight loss goal of 10.5lbs was broken down into weekly goals and a weekly weight loss goal of 1.75lbs agreed. In this example, the client over-achieved the set goal, which was to be expected based upon the starting weight. The weight loss goal set was achievable yet realistic, and clients that over-achieve weight loss goals are general y more motivated to continue. Therefore the goal set is important to success. This is an outline of weight loss over the first 6 weeks, giving a total weight loss of 11¼lbs. Mrs J continues to attend weekly appointments one year after the first consultation and currently weighs 10 stones 12½ lbs, il ustrating a loss of 4 stones 1½ lbs. She is fol owing a healthy, balanced diet and completing approximately 300 minutes of exercise each week. Evidence to incorporate into the case study recommendations above
Body Mass Index is only one measure of obesity, but is readily accepted as an accurate form of Although the key component in weight loss is ensuring calorie intake is lower than expenditure, there is a link between excess body weight and a sugar rich diet. The effect that sugar has upon blood glucose control, and resulting food choices, probably compounds weight issues2. Low GI foods can help with weight loss as a result of increased satiety fol owing prolonged gastric emptying and less impact on blood glucose control3. Consuming adequate protein in the diet and including protein in each meal can be beneficial for weight loss as it can improve satiety, heighten thermogenesis and potential y enhance lean tissue Increased portion size of meals is general y linked with higher energy intake and therefore weight gain. However, eating smal er portions of food can be psychological y difficult for many, so tips for keeping portions at a similar size but reducing the energy density of a meal, and/or ideas for making portions look larger should be used for success5. Energy expenditure is an important component for long term weight loss. Walking is an inexpensive, simple activity accessible to most people. The American Col ege of Sports Medicine recommend 200+ minutes of moderate exercise weekly for long term weight loss6. ___________________________________________________________________________ 1 NHS. NHS Choices (2013) Health Tools. BMI calculator. Avhttp://www.eatwel 2 Te Morenga L, Mal ard S, Mann J. Dietary sugars and body weight: systematic review and meta- analyses of randomised control ed trials and cohort studies. BMJ. 2012 Jan 15;346:e7492. doi: 3 Thomas DE, El iott EJ, Baur L. Low glycaemic index or low glycaemic load diets for overweight and obesity. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005105. 4 Paddon-Jones D, Westman E, Mattes RD, Wolfe RR, Astrup A, Westerterp-Plantenga M. Protein, weight management, and satiety. American Journal of Clinical Nutrition. 2008 May;87(5):1558S- 5 Ello-Martin JA, Ledikwe JH, Rol s BJ. The influence of food portion size and energy density on energy intake: implications for weight management. American Journal of Clinical Nutrition. 2005 Jul; 6 Donnel y JE, Blair SN, Jakicic JM, Manore MM, Rankin JW, Smith BK American Col ege of Sports Medicine Position Stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Medicine and Science in Sports Exercise. 2009 Feb;41(2):459- Weight Loss Case Study 2. Female, Age 31 Baseline BMI: 29.6.
Jenny was 31 when she attended her first nutritional therapy consultation. She weighed 13st 7lbs for her height of 5ft 7½ in giving her a BMI of 29.6. Jenny had chosen to consult a nutritional therapist as her weight had been increasing for some five years since starting oral contraception to control Polycystic Ovary Syndrome, and being in a settled relationship. A couple of months prior to her appointment, she had been diagnosed with hypothyroidism (free T4 10.8pmol/L (12.0-22.0 pmol/L); TSH 3.62 mIU/L (0.27-4.2 mIU/L)) and was prescribed levothyroxine at 25mcg daily. Her total cholesterol level was 6.8, down from 7.2 two years prior to her first nutritional therapy appointment. Jenny reported a number of signs and symptoms at her first consultation including regular mouth ulcers, flaky skin on head and anxiety/tension/irritability particularly after six hours or more without food. She described a lack of energy and reported that she was ‘not a morning person’. Jenny regularly felt tired after lunch and around 4pm, although she stated that she had more energy when taking regular exercise. Jenny had regular daily bowel movements and experienced no difficulty passing stools. Her menstrual cycle was regulated by OCP. In terms of family history, Jenny’s father had experienced thyroid disorders, alcoholism and hypertension. Her mother had bi-polar disorder. Jenny believed she had a ‘sluggish metabolism’ and was fat or ‘wel -covered’. She described her The key features of Jenny’s diet at her first consultation were: • 4x red meat per week, 4x poultry per week, 2-3x salmon or smoked mackerel/week • 3x fried food/week, 3-4x ready-made meals or fast food per week (curries, Chinese), 2x canned • 3-4x/week chocolate, sweets, cakes and biscuits • regularly consumed foods containing sugar • 1-2 cups of coffee per day but no tea • previously included alcohol most days but was trying to reduce to 5-7 units per fortnight. • gave up smoking a year ago. Previously smoked about 10 cigarettes/day for some 15 years. With regard to her lifestyle, Jenny had a stressful but enjoyable job in advertising which involved a lot of eating out and socialising and she spent a lot of time in front of computer at work. Jenny felt guilty when relaxing and frequently completed 2-3 tasks at once, although she slept wel for about 8h per night. She had recently restarted an exercise programme after a one year break. She was going to the gym 3x per week and was aiming to run a 5k race within six months of her first Jenny’s main goal for her nutritional therapy consultations was to lose weight slowly and healthily without dieting to reach 10-10.5 stone. She described how she had tried many dietary approaches in the past, but had not been able to sustain them. This time, she wanted to learn skills and tools that she could maintain on her own for long-term weight management in the future. The main focus of Jenny’s nutritional programme was intensive education with regard to the energy content of food including alcohol, portion control and dietary choices to help her achieve her weight loss goals. Jenny also received regular feedback (initial y weekly and ultimately monthly) on the Food Diary that she completed throughout her programme. This helped her learn how to manage As a result of this combination of education and regular coaching, Jenny achieved the fol owing Initial Results
Results after 14 months
At the end of her nutritional therapy programme Jenny felt that she had a much better understanding of how to manage her diet and her weight in the context of her busy life. Three years after completing her programme, she was maintaining her goal weight through a total lifestyle programme focused on diet, regular exercise and stress management.


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