A recent US study defined metabolic health as having ideal levels of blood sugar, triglycerides, high-density lipoprotein (HDL) cholesterol, blood pressure and waist circumference without using medications. All will recognise these markers as key components of metabolic syndrome, where obesity, type 2 diabetes (T2D) and cardiovascular disease are common, advanced metabolic end points.
While medication is the cornerstone of current treatment, lifestyle change may be particularly effective as it addresses the root cause. However, it can be difficult to implement and results vary widely.
Metabolic measurement can take the patient on a health journey. Indirect calorimetry, in similar ways to measuring blood pressure when managing hypertension, can be used to measure the effects of lifestyle interventions on a patient’s energy metabolism.
This technology is not yet commonly used in general practice, but its clinical potential has long been recognised. Daily caloric needs, fat utilisation and how efficiently energy is used are all measured. Coupled with pathology and body composition, it provides insight into how a patient’s metabolism affects their health. Thousands of tests confirm that patients with low levels of fat utilisation have trouble losing weight.
Evidence-based lifestyle interventions incorporating exercise and nutrition, informed by measurement and patient history, can then be implemented. The measurement and supporting data remove the guesswork associated with conventional lifestyle interventions and perhaps, most importantly, provides validation and motivation for the patient to continue.
Case study
A 53-year-old male patient was referred with a BMI of 28.3, T2D and NASH. Through dietary measures he had managed to lose 10kg and reduce his HbA1c from 9% to 6% but had stalled at 100kg for almost 18 months. T2D remission had motivated him to go further. Testing indicated poor metabolic efficiency and poor fat utilisation.
Resistance exercise and deeper intermittent fasting were recommended. This resulted in a further 20kg weight loss (without hunger, or significant muscle loss). His HbA1c is now 4.3%. Additionally, he has passed an OGTT and has maintained this total weight loss (30kg) for over two years.
Drawing conclusions from an n=1 is problematic, but it provides useful insights into reasons for success (or failure).
Weight-related metabolic disease is a global challenge and there is renewed interest in effective GP-led lifestyle management programs internationally.
With a major NHS program underway for T2D remission in the UK, for veterans in the US, and similar programs in Canada, Netherlands and Germany, hopefully Australia can also be part of the resurgence in lifestyle program targeting metabolic health.
A key challenge in general practice remains how to deliver and monitor effective lifestyle management at scale.
Developing integrated teams and including metabolism testing to current lifestyle programs may help to deliver real impact. Linking or embedding allied health within general practice could further improve the efficacy of these prescribed lifestyle interventions.
Key messages
- Managing obesity remains a challenge worldwide
- Objective measurements improve compliance and outcomes
- A team approach further assists.
– References available on request
Author competing interests – the author works with the company that owns the technology mentioned in the article