I would like to thank the organising committee for inviting me and for choosing lifestyle prescription. Yesterday I was happy to hear the speaker from the morning, everybody talking about lifestyle intervention. So I have no conflict of interest. The agenda of my talk will be about history of healthy lifestyle and evolution of guidelines for diabetes and obesity management, definition of lifestyle prescription, the component of lifestyle prescription, barriers to adhere and what is the solution. So the concept of balanced health or healthy lifestyle has indeed been evolved for centuries. So from the Roman, Egyptian, they are always talking about this balance between body, mind and nature and community. The father of medicine, Hippocrates, he said let food be the medicine and medicine be the food. He also talked about exercise and mentioned walking is the man's best medicine. So this concept of healthy lifestyle, it's not really new. Our prophet Muhammad's advice regarding health, diet and wellbeing is a rich source of wisdom that emphasises balance, moderation and mindfulness. Our prophet in the Sunnah said moderation in food, encourage physical activity and praying five times a day and that prayer is a kind of meditation and for us to unwind from the stress whenever we go and pray. But with the industrial evolution, our traditional lifestyle and this balance was disrupted and that led to the widespread prevalence of chronic disease. So no more balance with the industry. So what is the evolution of guidelines for diabetes management? So the guidelines, since the father of medicine mentioned let food be the medicine and medicine be the food and then we have Jocelyn 100 years ago prescribing a carbohydrate-restricted diet for diabetic patients way before the discovery of insulin. So we moved from holistic with the industry to diet-restricted carbohydrate to again the holistic approach where the patient is the centre and we have to prescribe lifestyle intervention, medication and be holistic. So we're moving from holistic back to holistic in a different way. All the evidence continues to demonstrate the benefit of weight loss to manage chronic diseases, diabetes, heart disease and all obesity-related complications. So we need weight loss to revise and get the benefit of, to delay complication and get metabolic benefit. So weight loss is the key in the management of most chronic diseases. So over the last 50 years, numerous clinical trials have provided strong evidence supporting the benefit of lifestyle prescription for management of diabetes. Lots of lots of clinical trials supporting the same concept. We have diabetes prevention program where it's a landmark study in US compared the effect of lifestyle intervention metformin and placebo. After three years, lifestyle intervention with weight loss around 7% with diet and exercise, they had 58% lower incidence of developing diabetes compared to metformin. The look-ahead trial, this study also followed adults with type 2 diabetes to assess the effect of lifestyle intervention aimed to weight loss and there was a short-term benefit in terms of glycemic control, but no long-term cardiovascular benefit. But the metabolic benefit in short-term was very evident. The UKBDS study, the long-term follow-up individual with newly diagnosed diabetes, again intensive lifestyle modification which include diet and exercise, helped improve glycemic control and reduce A1c and with that reduce the risk of complication. The direct study patient assigned to lifestyle intervention and here that group they gave them low-calorie diet and support versus the standard care. So in the direct study, they found 46% of the patient who had a very low-calorie diet achieved diabetes remission after one year. So lifestyle intervention do work. And because of that, all international guidelines for management of diabetes, hypertension and obesity and cardiovascular disease highlighted lifestyle prescription as essential component of the treatment. The hypertension guideline, the obesity guideline, cardiovascular guideline, the kidney guideline, all of them highlighted this component as a core for the management, lifestyle intervention. So what is the definition of lifestyle prescription? So lifestyle prescription, it's a personalized plan or set of recommendation provided by healthcare provider to help an individual adopt and maintain healthy behavior, aim to improve or manage medical condition. The goal of lifestyle prescription is to empower individual to take an active role in their health and well-being with focus on sustainable changes that improve their health and manage their chronic disease and promote overall wellness. It's the balance, health, the Asian time talking about it. What is the component of lifestyle prescription? So lifestyle prescription has five components. Dietary modification involves healthy eating pattern, control portion size, making choices that help with weight management and blood sugar control. Physical activity, at least 150 minutes per week of moderate intensity aerobic exercise or 75 minutes of vigorous exercise. Behavior strategy, which is stress management, cognitive behavior therapy and self-monitoring, goal setting and motivational interviewing to support long-term behavior change. In the management of diabetes or obesity, we need weight loss. So aim to achieve 5 to 10% weight loss through combination of diet and exercise to improve insulin sensitivity and overall health outcome. Support and counseling, providing ongoing support through counseling and guidance on sleep, smoking cessation and stress management. So this is not one-time thing. Chronic disease is chronic and lifestyle intervention has to be chronic and we provide support ongoing. Now when the first ADA standards of care guidelines were published in 1989, nutrition was mentioned in two sentences only, just two sentences. And now we have a comprehensive medical nutrition supplement, very detailed and I recommend all of you to go through it. Now the focus of it is to advise on variety of nutrient-dense food in appropriate portion size to make it enjoyable, so there has to be pleasure in eating, and to provide the patient with practical tool for developing healthy eating pattern. The evidence suggests that there is not an ideal percentage of calorie from carbohydrate, protein and fat for people with diabetes. So for carbohydrates we need to focus on high quality nutrient-dense carbohydrate source that are high in fiber and minimally processed, that's the key. We need to minimize processed food. Protein strong evidence support higher plant protein intake and replace the animal protein because it's associated with lower risk of cardiovascular all-cause mortality from cardiovascular mortality. Fat, the type of fat consumed is more important than the total amount of fat. And it's recommended that the percentage of total calorie from saturated fat should be really limited. The sweetener, there is mixed evidence in the systemic review. Some findings say it help weight loss and others it promote weight gain. If the patient can live without it, it's better because it's not natural. For many individuals with overweight and obesity, 5% weight loss is needed to achieve beneficial outcome in glycemic control, lipid and blood pressure. And for that in the guideline they went into detail about eating pattern which is the totality of the food and beverage consumed over a given period of time. Example of eating pattern, we're talking about Mediterranean diet, DASH diet, low carb diet or Atkin diet. And the eating plan which is an individualized guide to help plan when, what, and how to eat on daily basis. Dietary approach in RCT found that two meal planning approach for diabetic, either diabetic plate method or carb counting method both lead to help in achieving lower A1C. And then the meal replacement which is basically a meal pre-packed food out of bars, shake or soup that contain a fixed amount of macronutrient and micronutrient and the goal is to replace one of the meal. So following any of these prescriptions can help in weight reduction. Of course it's not alone. Now evidence for eating pattern has been informed by RCT, prospective cohort studies, systemic review and net meta-analysis. And those are the most frequently referenced eating pattern, Mediterranean, DASH, low fat, carbohydrate, vegetarian. And Mediterranean diet is one of the most studied dietary pattern linked to positive health outcome, particularly for cardiovascular health. And the diet emphasis on high consumption of fruit, vegetable, whole grain, legume and nuts, healthy fat, especially olive oil, moderate intake of fish and poultry, limited consumption of red meat and processed food, and low to moderate intake of daily primary cheese and yogurt. Research has shown that Mediterranean diet can reduce the risk of cardiovascular disease, improve lipid profile and support overall health, heart health. Evidence suggests also that DASH diet not only improve short-term blood sugar and weight control but it has long-term benefit for diabetes and obesity management. DASH diet, initially it was for hypertension. It focused on reducing sodium, increasing fruit and vegetable, rich in antioxidant fiber and healthy fat, and it shows strong evidence for improving cardiovascular outcome. Intermittent fasting or time-restricted eating, a strategy for weight and glucose management, has been studied extensively and the evidence really is supporting its benefit. And there are three types of fasting. We have alternated day fasting, energy restriction of 500 to 600 calories on an alternated diet, or 5-2, energy restriction of 500 to 600 calories on consecutive and non-consecutive days with usual intake the other five days, and time-restricted eating, which is the 16-8, daily calorie restriction based on their window of time. What we notice in our area, in the MENA or in the Gulf area, people eat all the time and it's mainly carb-based diet. So when we provide this intermittent fasting, they see a wonderful result. So we need to teach them slowly not to do the frequent snacking and eating, and if they can restrict to three main meals or maybe two meals without snack, it will improve their blood sugar and their weight and the overall health of cardiometabolic. Dietary advice for diabetes is to manage glucose and also to provide sustainable weight loss. So the focus on carb control, to choose complex carb from whole grain, vegetable, and limit simple sugar, and monitoring portion size and carb intake is very essential. We ask the patient to take low glycemic index food that has slower, more gradual rise in blood sugar, and fiber-rich diet, which increase fiber intake to improve their blood sugar. And we advise them in meal timing and portion control, which consists of scheduled meal, and to limit processed food, because that's really the killer in our practice. People really depend on processed food and packed food. For a patient with obesity, the focus on reducing calorie intake and ensuring nutrient advocacy and promote sustainable weight loss, calorie reduction, tailor calorie intake to energy need, typically by reducing the intake by 500 to 1,000 calorie per day for gradual weight loss. Portion control is very important to use smaller portion to avoid overeating and encourage mindful eating habit. The patient need to sit, chew, and eat slowly. No need to eat and rush. That's very complex. We promote a really balanced diet, which include all food group in a moderate amount. Fruit, veggie, lean protein, whole grain, high protein intake with low calorie, and to avoid empty calorie, which is really the snack, the processed snack, and soft drink, the Karak tea, now the fashion in this area, and to limit high fat food, which is saturated fat. So it's very difficult, since in our culture they focus on food, to shift. So ask them and advise the patient to take it slowly and support in the choices. And there is also in the guideline for ADA a comprehensive detail about physical activity recommendation as a core component of lifestyle intervention, because the patient will come to you and they'll tell you, we don't eat. It's one meal a day, but I'm not losing weight. So you need to go back and take a history. What about physical activity? So physical activity is the term, general term, that include all movement that increase energy use, and it's an important part of diabetes management plan. Exercise is the most specific form of physical activity that is structured and designed to improve physical activity. When we take a history and ask about a patient, do you exercise, they'll tell you yes. So tell us more about that exercise. Well, we walk 10 minutes twice a week. Now that's not exercise. That's definitely not exercise. All exercise is physical activity, but not all physical activity is exercise. So your prescription and recommendation for the patient, it will vary based on the age of the patient, duration of diabetes, presence of any complication or insulin or other medication. So practical tip for increased physical activity, they need to do a variety of exercise. You can ask the patient, what type of exercise do you do? Of course, there will be a shocking answer, nothing. I don't like to move. Then you need to motivate them, because there's so much exercise. There's aerobic exercise, strength training, flexibility and balance. And so you need to educate them about the benefit of physical activity. And always I tell them, there is no one prescription will benefit you like exercise. You can take all your medicine, but for your health, you do need that exercise. Frequency, try to spread it throughout the week, but better even to spread it throughout the day. So they move from sitting position, do maybe meeting while standing or playing the computer, do your presentation while standing or try to do maneuver where you have active, being active throughout the day. Activity starts slowly, of course, and gradually increase the duration and intensity to avoid injury. Monitoring blood sugar is very important. Stay hydrated is very important. Counsel your health provider. And the most important is to enjoy that activity. So go out with a friend or some family member. So it's enjoyable physical activity and incorporate it in your daily activity is the best. Because one of the main complaint about the patient, they'll tell you, we don't have time. So if you go into detail about that time, they basically do nothing. They don't study. They don't work. They have help at home, but they don't have time to exercise. And you wonder how is that possible? Now in the ADA, there is a comprehensive chart to describe how to be active 24 hours. It's very useful. And it gives indication about the benefit of cardiometabolic health. So basically it decrease glucose, it decrease blood pressure, A1C, libid, and it increase the well-being quality of life and it decrease depression, most of the physical activity. Psychological care is covered as part of the overall comprehensive diabetes care. So we need to screen the patient for depression, anxiety, diabetes distress, and eating disorder. Diabetes distress is very, very common because diabetic patient are really overwhelmed with the things they need to think about. They have full-time job or study and they have to worry about blood sugar, about monitoring, about medication, about food. So much things to think about and to plan. So they do develop diabetes distress. Psychological support offer cognitive behavior therapy to them and other mental health intervention. As I mentioned, diabetes distress burden to improve self-care and clinical outcome. You need to address it. And integrated health. These include psychosocial support in comprehensive diabetes care for better health overall health. Now all health provider need to practice integrated care by screening the patient for any mental disorder. And this is the situation where you need to refer the patient to really a specialist psychologist or psychiatrist. So not all institute have psychologist. But at least we do the basic screening. We address the mental issue. And if we discover any of those parameter, then we refer the patient to a psychologist. We cannot ignore. So if we don't screen, we will not identify this entity which is really affect their glycemic control and complication. Smoking cessation, it's very important because smoking increase the risk of developing type 2 diabetes and complication such as heart, kidney, and poor circulation. So we need to educate the patient about the danger of smoking, all type of smoking. And we need to screen them and offer them help and referral how to address smoking cessation. Sleep. Yesterday we had a very good talk about sleep disorder. And sleep disorder really is a risk factor for developing type 2 diabetes. So we need to screen for sleep health in people with diabetes, including symptoms of sleep disorder or disruption of sleep. Refer to sleep medicine specialist and to qualify behavior health professional as indicated. Counsel people with diabetes to practice sleep, promoting routine and habit. Maintain consistent sleep schedule and limit caffeine in the afternoon. Of course, in this area, it's becoming people like to stay late and wake up late, especially in our young people during holiday or weekend. So always promote early sleeping and good quality sleep. And if we do it as parents, the kids will do it. So we cannot advise our children to do it, and we're running and roaming around doing other things. So what is the barrier to adhere to lifestyle intervention? Well, habits and routine. Many people have established eating and activity habits that are hard to change. Break these routine can feel very overwhelming. Social influence. So social gathering in our area, we gather around food and the center of any social activity. So when we advise them to adhere or change their dietary goal, it's kind of pressure. So there is peer pressure for unhealthy practice. So it's very complex. Emotional factors, stress, anxiety, emotional eating, or lack of sleep. This can lead to unhealthy eating choices, making it difficult really to stick to a healthy lifestyle intervention. Time constraint. So without proper understanding of nutrition and exercise, sometime planning and allocate that time for your health is very difficult. So we need to educate our patient about the importance of health and exercise and sleep and stress management for their overall health. Quick fix. People want to do exercise for a few weeks and see the perfect result. So lifestyle changes, it's a long term, and we always tell the patient we don't like the concept, the word of diet. It's lifestyle intervention. It's a chronic and it has to be chronic. Access and cost. So not everyone has access to healthy food. Sometime membership to a gym is very expensive, or buying good food, good quality food is expensive. Medical condition, certain condition can be an issue for a patient to exercise or it's difficult for them to follow certain diet or exercise. Motivation and mindset. So maintaining that motivation can be tough. To motivate yourself to go and exercise is not easy. So what is the solution? How can we solve it? Now we understand, I think all of you convinced, like lifestyle intervention is very important. But how to adhere to lifestyle intervention? How to make it easy for our patient? Well, we need to personalize plan, tailor intervention to fit the patient need. And for that we need detailed history. And we need to set goals, specific goals, ask deep history. Why you want help? You want to play with your kids, with your crying kids? You want to travel? So set that, motivate them through that goals. Adhere any barriers. Identify that obstacles and discuss with the patient. Behavior technique, motivational interview, positive reinforcement, and encourage self-management to wear the tracker for physical activity, keep tracker of their diet that can motivate them or be part of a support group where they encourage each other. Regular follow-up. So don't give this prescription and leave the patient alone to see him again in three months or six months. They have to have access to you. They have to have a channel of where they contact you and motivate them. So in our center, the nurses always follow up the patient through WhatsApp. They put them in a group. And that follow-up really encourage the patient to move on. That road was wavy, this one is straight. So to improve, we need really to build support network, provide resources, make it enjoyable. If the people don't enjoy the food, they will not eat it. If they don't enjoy that physical activity, they will not do it. So whatever lifestyle prescription, make it specific, tailored to that patient, and really enjoyable. And model behavior. So choose some celebrity who does that. Ask them to follow anybody who really has an impact where they see them as model. And celebrate success. This is very important. You need to, patient like that celebration of success. And with that, I will share with you what few cases from the National Diabetes and Endocrine Center where every year we celebrate success. These patients, they follow lifestyle intervention, and they lose wonder. In like a year or so, they lose 20 kilos, 50 kilos, just by putting them in this different stages of lifestyle intervention with the multidisciplinary team. And in detail, I'll talk about Mama Fatima, we call her. She came to us in 2015, 74 years old lady with diabetes for 20 years. Her GFR 72, BMI was 60. With lifestyle intervention, she lost weight, stopped insulin. So after five years, her BMI became 31. So from 129 kilo to 68 kilo over five years. She received so much award in the World Obesity Day celebration. And she's only on GLB-1 and lifestyle intervention. So lifestyle intervention do work, but you need to get your team ready and support the patient. And with that, thank you very much.

lifestyle prescriptions

chronic diseases

dietary modifications

Diabetes Prevention Program

behavior strategies

patient success stories