Mr X is a 67 year old man with heart failure (reduced ejection fraction 37%) presents with sub-clinical depression (PHQ9 = 9) and pre-diabetes (elevated IFG 110mg/dl).  He has a BMI of 35 and waist circumference >102cm. His medications include Neiblet, Atorvastatin, Rivaroxiban, Spironolactone, Entresto, and supplements include Vitamin D, and CoEnzyme 10. 

Mr X is very medication compliant so his existing symptoms and risk factors are well controlled (HF, AF, hypertension) with the exception of his weight and recent test IGT result, which he feels are driving his low mood. He cannot achieve weight loss largely due to impaired mobility and respiratory functioning which limits his physical activity. He is feeling low, guilty and worried that his pre-diabetes will progress to T2DM and is overwhelmed by the prospect of managing another comorbidity. He has reasonable diet and health literacy and shows a desire to change however he has stated that he is “fussy” with his dietary intake. His wife does all meal preparation so Mr X generally shows a lack of ownership to his dietary intake. He successfully lost up to 20 kgs in the past when he was younger and more much physically active using a traditional low fat approach and intensive exercise.

Since his HF diagnosis 5 years ago he cannot maintain dietary change for longer than 2-3 weeks before resorting back to old dietary habits (especially when his wife is not around) which is characterised by high levels of carbohydrates and sugars. Aside from slow paced walking, he is largely sedentary at his desk job. As a result, Mr X’s BMI has remained elevated since then and he is now seeking health professional assistance to lose weight.   

In this discussion:

1. What type of dietary intervention with respect to macronutrient profile would you recommend to simultaneously target Mr X’s mood, IGT and weight?
2. Is this patient a good candidate for time restricted eating, low energy diet, and/or intermittent fasting and if so, for how long?
3. What considerations might need to be made when initiating any of these dietary interventions in view of his current medication regime and comorbidities?
4. Would you recommend further nutritional supplementation?
5. Which marker would you use to measure effectiveness of the dietary intervention in this patient?  (waist circumference, % weight loss, IFG, PHQ9, LVEF, 6 minute walk test, Quality of Life, other?)
6. What would you consider doing differently if Mr X was a woman?
   

Recommended Readings:

Jacka (2017) A randomised controlled trial of dietary improvement for adults with major depression (the ‘SMILES’ trial). BMC Medicine 15:23

Sanchez-Villegas (2013) Mediterranean dietary pattern and depression: the PREDIMED randomized trial BMC Medicine 11:208

Lean (2018) Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet, Volume 391, Issue 10120, 541-551

Christensen (2018) Men and women respond differently to rapid weight loss: Metabolic outcomes of a multi‐centre intervention study after a low‐energy diet in 2500 overweight, individuals with pre‐diabetes (PREVIEW) Diabetes, Obesity and Metabolism.  https://doi.org/10.1111/dom.13466

Kitzman (2016). Effect of caloric restriction or aerobic exercise training on peak oxygen consumption and quality of life in obese older patients with heart failure with preserved ejection fraction: a randomized clinical trial. JAMA. 2016;315:36–46.

https://foodandmoodcentre.com.au/
https://www.moodfood-vu.eu/
www.previewstudy.com

Information about the discussion leader

Associate Professor Adrienne O’Neil is a behavioural scientist and epidemiologist at the Universiy to Melbourne, Australia. She leads a program of research focussing on the relationship between mental disorders and cardiometabolic conditions, including shared risk factors, pathways and interventions. She has been involved in several seminal dietary and lifestyle based intervention trials including the Australian Diabetes Prevention project (2007), Proactive Heart trial (2012). MoodCare trial (2014), and the recent SMILES trial (2017) which was the first study to show that the Mediteranean diet was efficacious in improving clinical depression in adults. She is funded by the Heart Foundation of Australia.

This is the second in a series of discussions introducing some of the programme sessions that will be featured at the IDF Congress 2019 in Busan, Korea, 2-6 December 2019.