Is there a practice-based future for personalised nutrition Elisabeth Govers, RD Nutrition Working Group EFAD/EASO

Definitions The use of food to promote health has a very long history: Dietetics: the science or art of applying the principles of nutrition to the diet. Word first used 1799 (Oxford Dictionary). Dietitian: a specialist in dietetics (Merriam Webster Dictionary). Word first used 1846. Diet: 1. the kind of food that a person, animal, or community habitually eats. 2. a special course of food to which a person restricts themselves, either to lose weight or for medical reasons. Synonyms: dietary regime, dietary regimen, dietary programme. The use of food to promote health has a very long history: “Let food be thy medicine and medicine be thy food.” Hippocrates, c 460-370 BC

The definition of a European dietitian is: Dietitians are autonomous healthcare professionals who assess specific nutritional requirements of populations or individuals throughout the life span and translate this into advice which will maintain, reduce risk to or restore people’s health. Using evidence-based approaches dietitians work to empower individuals, families and groups to provide or select food which is nutritionally adequate, safe, tasty and sustainable. Beyond healthcare, dietitians improve the nutritional environment for all through governments, industry, academia and research Dietetics is the assessment of specific nutritional requirements of populations or individuals throughout the life span and the translation of this into advice which will maintain, reduce risk to or restore people’s health. Beyond healthcare, dietetics improves the nutritional environment for all through governments, industry, academia and research. Statement by the European Federation of the Associations of Dietitians (EFAD), 2015

Role of the dietitian in Obesity Dietitians play a key role in the management of obesity in adults and children at every level. They are uniquely qualified to translate the scientific evidence on energy intake and expenditure, nutrition and behavior into practical dietary advice and the provision of healthy food. Dietitians use counseling techniques to support individuals and groups who are overweight or obese or have obesity related conditions, such as diabetes and coronary heart disease, in an effective way both short term and long term EFAD Position Paper, 2010

Dietary diagnosis The combination of personal, social, psychological, medical, physical, nutritional characteristics of an individual that influence both the health and the response and outcomes of the treatment by a dietitian. For example: stress, sleep, exersize, financial situation, but also coping techniques in contact with family and collegues of a patient can influence the outcomes of the treatment. Whether a patient will be able to make healthy choices and adhere to a food pattern is dependent on these factors. The dietitian will diagnose those elements and address them, sometimes in combination, or one by one. Essential for the dietitian: health counseling techniques, empathy and social skills Plus a thorough knowledge of dietary guidelines

In short A dietary advice given by a dietitian is by definition personal, and therefore personalised nutrition. This advice is always practice based, because although it starts based on evidence based dietary guidelines, these are adjusted to the patients needs and possibilities. This is also the reason why clinical and primary care dietitians are never satisfied with handing out general guidelines to their patients: NOT TWO PATIENTS ARE ALIKE IN THEIR NEEDS & POSSIBILITIES

PERSONALIsED nUTRITION Diets that are well known for individual approach: FODMAPS Diabetes type 1 and 2 Glutenfree diet Malnutrition Cardio Vascular Disease (hypertension; dyslipidemia; triglyceridemia) Food allergies Crohns disease & colitis ulcerosa Diets for patients with cancer Overweight and obesity Personalised diets for overweight and obese patients are still questioned, as if one approach would fit all

Personalised Nutrition The nutrients we consume can affect the way our genes are expressed; Our genes are able to influence how our bodies respond to these nutrients. Personalised nutrition is looking at the complex interaction between nutrients and genes to create tailored diets which complement a person's unique genetic profile. The idea of personalized medicine was first introduced by Roger William in the 1950s. It became more attainable only in the early 2000s, when the human genome was mapped, and scientists could study the subtle individual genomic differences. It was soon predicted that personalized nutrition would be the future nutrition model, and that the future delivery of nutritional knowledge would be digital

Food4Me A EU-funded  multi-center study as a proof of principle that a fully internet delivered personalised nutrition advice could make a difference in people’s lifestyle. The project envisaged personalized nutrition advice at three levels: The person’s diet only The diet combined with knowledge of the person’s phenotype (measurable traits, such as physical and biochemical measurements, e.g. height, weight or cholesterol level), The diet, phenotype and genotype (that determine a person’s heritable gene identity; e.g. a gene variant associated with weight gain). The study population filled out an internet delivered, food frequency questionnaire for personalized dietary analysis. It allowed for a feedback based on the subject’s prevailing food choices.

Outcomes 1200 people from 7 participating European centers, were randomized to one of four different types of advice: No personalized advice, only directed to open access healthy eating websites within their country (control group). The three other groups received personalized feedback based on: Diet alone, Diet and phenotype, Diet, phenotype and genotype. The personalized nutrition groups performed better at improving dietary intake compared to the control group, regardless of the advice level. When comparisons were made across the three personalized groups, there were no significant benefits of combined approaches above the personalized dietary feedback, suggesting that personal is what matters most. Rui Poinhos, PLoS One, 2014

Review on personalised nutrition Those individuals who perceived most benefits to be associated with personalized nutrition, perceived that they could achieve these health goals, and those who had greatest trust in those regulatory and control systems designed to promote consumer protection were the most likely to adopt personalized nutrition. Issue still to be tackled: secure handling of personal data. Stewart-Knox, Proc Nutrit Soc, 2015 Personalized nutrition in this concept is not personal at all, because the individual as human being is unknown and treated as an algorithm In some countries it is not allowed to give advice on this level if the patient is not seen

Obesity1 ICD-11 criteria Sick fat disease Fat mass disease Insulin resistance IGT Hypertension Type 2 diabetes Cardio Vascular Disease Dyslipidemia Gout Astma Allergies Osteo arthritis Sleep apnoea Coxarthrosis Gonarthrosis Eating disorders ICD-11 criteria

Obesity1 Not insulin resistant Insulin resistant Sick fat disease Fat mass disease Insulin resistance IGT Hypertension Type 2 diabetes Cardio Vascular Disease Dyslipidemia Gout Astma Allergies Osteo arthritis Sleep apnoea Coxarthrosis Gonarthrosis Eating disorders Not insulin resistant Insulin resistant

Percentage weight loss after 6 months % Weight change 1-3 months treatment 3-6 months >6 months Chi square test P value Including population intended to treat Loss ≥15% 2 (0.7%) 10 (2.3%) 13 (4.3%) <0.001   Loss ≥10-14.9 % 25 (5.7%) 34 (11.3%) Loss 5-9.9% 24 (8.9%) 103 (23.7%) 79 (26.2%) Loss 1-4.9% 96 (35.6%) 168 (38.6%) 112 (37.1%) Stable weight - 1/+1% 116 (43.0%) 67 (15.4%) 38 (12.6%) 454 (100%) Weight gain ≥1% 30 (11.1%) 625 (14.3%) 26 (8.6%) Median -0.6±4.2 -2.8±5.3 -4.0±5.4 -0.18±4.5 Mean -1.48 -3.5 -4.8 -2.27 Missing 545 Govers et al, 2008.

Weight loss related to diet after 6 months* <3% or no weight loss Hypo caloric diet 29.1% RGV 34.2%** Low fat diet 28.6% Low carb/high protein diet 46.1% Hypo caloric diet 41.7% RGV 35.9% Low fat diet 28.8% Low carb/high protein diet 28.8% >5% loss of waist circumference <3% loss of waist circumference Hypo caloric diet 40% RGV 38% Low fat diet 25% Low carb/high protein diet 57% Hypo caloric diet 37.9% RGV 35.8% Low fat diet 62% Low carb/high protein diet 42.8% *57% comorbidities; **Dutch National Dietary guidelines Govers et al. 2008

EFAD Survey on Dietary management of obesity

Rationale To improve the quality of prevention and management of obesity it is important that health professionals use evidence based guidelines. Dietitians in an European survey carried out by the European Specialist Dietetic Network (ESDN) on Obesity reported to work according to national guidelines in 76.7% of the cases; 84% of those guidelines were multi-disciplinary.  On the other hand, working according to guidelines may improve quality of obesity care but does not guarantee successful weight loss on an individual level. The ultimate goal in weight management should be loss of body fat, preferably abdominal & visceral fat, loss of waist circumference & reduction of comorbidities. To reach this objective, a personalised diet is essential. We also need to take medication a patient uses into account, because it can interfere with the diet & energy metabolism

RCT versus practice in Obesity management Only patients that fit the inclusion criteria Structured program Set frame of time Any patient needing certain care N=1! Program adjusted to the needs & possibilities of patient Time dependent on needs patient

Is a RCT design fit for obesity research? “In addition, the use of a RCT design in dietary interventions may not be appropriate. (….) It is clear that patients are changing their treatment by their own accord, perhaps subconsciously or perhaps due to a metabolic response of the body aiming to return to its initial weight. The current thinking within the field of obesity suggests that the use of continuous improvement methodology may be more appropriate for weight-loss management.” Hession, Obesity Reviews 2009

Conclusions Personalised nutrition is essential in obesity management Weight loss in non research setting takes time -> the longer the treatment the larger the weight loss Patient with sick fat disease needs other diet than patient with fat mass disease Not every diet fits every patient! Patients have their own experience with diets that lead to successful weight loss: listen to the patient Until research has solved the problem of perfectly matching an individual to a diet, flexibility in choosing among many diets with measurement of intended outcomes in individual patients should be recommended. The ultimate goal in weight management should be loss of body fat, preferably abdominal & visceral fat, loss of waist circumference & reduction of comorbidities & improvement of quality of life

Thank you! Questions The Nutrition Working Group is a joint committee of EASO and EFAD.