Lifestyle management + interventions for weight loss

Lifestyle changes are the cornerstone of management of CKM disease at all times, but need to be tailored to the individual. In particular, lifestyle changes should not delay urate lowering therapy in gout.
There are 6 key areas of lifestyle management in CKM disease:
- Education and support
- General care
- Healthy eating
- Interventions for weight loss
- Physical activity
- Healthy sleep
Education and support
- Adequate education and support are essential in empowering all individuals and whānau to self-manage their CKM disease and achieve best outcomes.
- Utilise all members of the multidisciplinary team available to optimise care as required. In addition to the GP and nursing team, many practices now have access within the practice, PHO or community to team members including:
  - Kaiāwhina or health navigator
  - Pharmacist
  - Dietitian
  - Health coach
  - Health improvement practitioner
  - Psychologist
  - Social worker
  - Podiatrist
  - Comprehensive Primary Care Team (CPCT)
- Utilise locally available relevant courses and programmes e.g. Green Prescription, Diabetes Self-Management Education (DSME) etc.
- Strongly consider referral to culturally appropriate services e.g. Kaupapa Māori Services or Pacific Health providers if available
- Strongly consider referral for psychology input if significant distress from CKM disease and/or if depression is present
- Provide information on community support groups as applicable e.g. Stroke Aotearoa, Heart Foundation, Kidney Health New Zealand/Kidney Society and Diabetes NZ etc.
General care
- Smoking cessation remains critical and should be offered yearly if smoking
- There is increasing evidence that vaping may increase the risk of CV disease, lung disease and heart failure. Consequently, vaping should likely only be seen as an interim measure for stopping smoking
- Discuss reduction of alcohol intake and other recreational drugs as required
- Ensure vaccination status is up to date given greater adverse effects of communicable diseases in people with CKM disease
- Ensure cancer screening as per national recommendations is p to date given greater risk of solid cancers in CKM diseases
- Screen for depression and treat as required as high risk of depression in CKM diseases
- Screen for diabetes distress if known diabetes
- Contraception and pregnancy advice should be discussed in women of childbearing age
  - Risks of pregnancy and contraception will be affected by the stage and degree of CKM disease, but the risks of pregnancy are almost always greater than the risks of contraception.
- Optimise treatment of non-CKM diseases that increase CV risk – these include but are not limited to:
Healthy eating
- Healthy eating is essential for all people with CKM disease, irrespective of body weight. General principles include:
  - Consider that the unequal distribution of poverty and obesogenic environments means Māori and Pacific populations are exposed to more risk factors for the development of CKM disease
  - Strongly consider referral to a dietitian if available
  - Reduce processed foods as much as possible as these are often high in sodium, sugars and fat, and low in fibre
  - Low salt intake - < 2 g of sodium or < 5 g of salt per day
    - Advise not to add salt to food and avoid processed foods
  - Reduction of excess carbohydrates particularly sugary drinks and confectionery
    - Low glycaemic index carbohydrates preferred
  - Reduced animal-sourced saturated and trans fats
  - Aim for at least 5 servings of fruit and vegetables per day and to increase plant-based intake
    - Bananas, potatoes, tomatoes and leafy greens useful sources of increasing potassium intake, which is important in reducing BP + CV risk
  - Maintain protein intake – fish, poultry and nuts useful sources and limit red meat
    - Healthy plate model is useful to demonstrate portion sizes
  - Ensuring at least 30 g of fibre per day – whole grains useful source
  - If history of gout:
    - Whilst the intent is not to make food the central point of discussion, reducing alcohol and high sugar food and drinks may be appropriate, including avoiding foods that have previously triggered gout flares (if any). Advising against traditional kai e.g. kaimoana (seafood) is inappropriate and once urate levels are to target, previous dietary triggers are often well tolerated.
    - Ensure adequate fluid intake (e.g. 2 litres of water per day) if no concerns of fluid overload. Eating regular meals is also likely helpful as flares can be triggered by both fasting and overeating.
Interventions for weight loss
- A personalised weight loss plan with evidence-based advice is strongly recommended for all people with CKM disease with excess adiposity. Key targets for weight loss include:
  - 5% total body weight loss significantly improves the majority of metabolic parameters including glucose levels, blood pressure, and lipid studies. This may allow for a reduction in medications, but typically, greater weight loss is required for remission of CKM disease.
  - At least 10-15% total body weight loss is typically required to achieve remission of:
    - Type 2 diabetes
    - OSA
    - Hypertension
  - At least 15-20% reduction in total body weight loss is required to achieve remission of:
    - MASLD
    - Heart failure with preserved ejection fraction
  - NB: It is crucial that conversations about weight loss are conducted in a positive, culturally safe and non-judgmental manner. The focus should be on weight loss for health reasons with ‘medical targets’ rather than societal targets or ‘ideal weight’.
    - Any weight loss is beneficial and will have a positive ‘legacy effect’ lifelong
    - Supportive care is essential because sustained weight loss can be difficult as obesity is typically a lifelong remitting and relapsing disease. Body weight is vigorously defended by increased appetite and reduced mitochondrial energy expenditure through no fault of the patient. Supportive care includes:
      - Whānau-based strategies which are likely more effective
      - Psychology input if any concerns of disordered eating or depression
      - Dietitian input to guide nutritional plan. If dietitian is not available then health coach or health improvement practitioner is a useful alternative
      - Enquiring about food security and utilising social worker, kaiāwhina and health navigator input
      - Referring to local weight loss programmes if suitable and available
      - Considering pharmacotherapy and bariatric surgery for weight loss if possible
- There is currently no conclusive evidence that any nutritional strategy is superior to any other. Pragmatically the best nutritional strategy for weight loss is the one that works, is nutritionally complete and is sustainable. Current evidence suggests best strategy to achieve long-term weight loss and reductions in CKM disease are:
  - Very low energy diet with meal replacement e.g. DiRECT style intervention
  - Mediterranean diet
  - Dietary approach to stop hypertension (DASH) diet
    - Modified Mediterranean diet with low salt
  - Plant-based diets
  - Other strategies shown to be safe and effective in the short-term include:
    - Very low carbohydrate or ketogenic diets
    - Intermittent fasting
    - Low glycaemic index diets
    - Commercial weight loss programmes
  - NB: Choice of strategy is often determined by personal preference, cultural acceptability, tolerability, affordability and nutritional adequacy
    - Ensure adequate nutrition in children, pregnancy, breast feeding and in the elderly or anyone at risk of sarcopenia
      - Remember being mildly overweight is protective if elderly
      - Adequate protein intake and physical activity is important in maintaining muscle mass
      - Utilise dietitian resources if possible
  - Although nutritional strategies are the cornerstone of management of weight loss, pharmacotherapy to aid weight loss should be considered if BMI > 27 kg/m² with at least one obesity comorbidity and unable to achieve weight loss targets despite not being funded. Options include:
    - Phenetermine (Duromine) ± topiramate
      - Cheapest agent at ~ $80/month
      - Sympathetic side effects may limit use particularly if CV disease
        
        Do not use phentermine if CV disease, arrhythmias, untreated hypertension or thyrotoxicosis, substance abuse, pregnancy, breastfeeding or children
        
        Phentermine 15 mg daily appears best dose as similar efficacy with less adverse effects than higher doses
        
        NB: Common misconceptions are that phentermine is addictive and can only be used for up to 3 months, which are untrue.
        
        Topiramate for weight loss is off-label in NZ but consider if cost an issue
        
        Topiramate is typically started at 25-50 mg daily and increased up to doses of 100 mg daily for weight loss. Beware of teratogenic effects of topiramate.
        
        Topiramate may also be useful if history of migraines or epilepsy
    - Orlistat (Xenical)
      - Cost is ~ $120/month but not used commonly due to GI adverse effects
        
        Best to use orlistat with a low fat diet with doses of 120 mg with main meals
    - Buproprion ± naltrexone (Contrave in combination)
      - Cost of Contrave ~ $250/month
        
        Contrave tablets contain 8 mg of naltrexone and 90 mg of bupropion
        
        Typically start at 1 tablet per day and increase by 1 tablet per week up to 2 tablets twice daily or maximal tolerated dose.
        
        Slow down dose increases if GI adverse effects e.g. nausea
        
        GI adverse effects typically dissipate within 2-3 weeks
        
        Do not use in pregnancy, breastfeeding, children, uncontrolled hypertension, history of seizures, bipolar disorder, MAOI use or withdrawal of alcohol or benzodiazepines etc.
      - Bupropion alone for weight loss is off-label in NZ but can consider if cost an issue. Bupropion ± naltrexone useful if low mood or to help smoking cessation
    - GLP1 receptor agonists (GLP1Ra)
      - Likely most effective pharmacological for weight loss. All current GLP1Ra in NZ are subcutaneous injections.
        
        Ensure prescribe with 4 or 5 mm BD fine insulin needles
      - Aim to use funded liraglutide (Victoza) or dulaglutide (Trulicity) if possible if type 2 diabetes as expensive to self-fund (currently > $480/month)
      - Liraglutide (Saxenda) was principal GLP1Ra used for weight loss in NZ but Semaglutide (Wegovy) and Tirzepatide (Mounjaro) now available (unfunded), which typically lead to greater weight loss and CV protection than liraglutide.
      - Doses and tips to avoid adverse effects can be found here.
        
        Liraglutide (Saxenda) can started at 0.6 mg daily and unlike in diabetes, liraglutide can be titrated to 3 mg daily or maximal tolerated dose
        
        Semaglutide (Wegovy) and Tirzepatide (Mounjaro) are now available and typically lead to greater weight loss and CV and renal protection than older GLP1Ra but are not funded
        
        Semaglutide can be started at 0.25 mg weekly and increased slowly to 2.4 mg weekly or maximal tolerated dose
        
        Tirzepatide can be started at 2.5 mg weekly and increased slowly to 15 mg weekly or maximal tolerated dose
        
        Tips should be provided for all GLP1Ra on how to reduce adverse effects:
        
        Ensure adequate hydration and stop eating when feeling full
        
        Eat smaller meals and avoid alcohol, fatty and spicy foods
        
        Slow down dose increases if GI adverse effects
        
        GI adverse effects typically dissipate within 2-3 weeks
        
        Doses of sulfonylureas may need to be reduced by 50% and doses of insulin by approximately 20% to avoid hypoglycaemia when starting GLP1Ra:
        
        Typically only required if baseline HbA1c < 64 mmol/mol
        
        Do not use in pregnancy, breastfeeding , children < 10 years of age, significant GI disease or medullary thyroid cancer
        
        GLP1Ra should be stopped once eGFR < 15 mL/min
    - Metformin may be used ‘off-label’ for weight loss but typically only leads to a maximum average of 2 kg weight loss. Empagliflozin is not recommended for weight loss unless treating underlying type 2 diabetes, renal disease or heart failure.
    - Typical approach with pharmacotherapy is to treat for 3 months to determine if ‘responder’, which is defined as ≥ 5% total body weight loss in time period.
      - If ‘non-responder’ → consider different pharmacotherapy for weight loss
      - If ‘responder’ → aim to continue treatment until weight loss plateaus. Can then consider:
        
        Dose reduction or cessation but weight regain is common.
        
        Continuing current dose to ensure weight stability
        
        All pharmacotherapy above safe for at least 3 years
        
        Switching to or adding in alternative pharmacotherapy agent
        
        Do not use phentermine and bupropion in combination
  - Consider bariatric surgery if failure to reach weight loss targets on all other interventions
    - Access to funded bariatric surgery is difficult, and regional variations in indications. But consider if:
      - BMI > 40 kg/m² or BMI > 35 kg/m² with other features of CKM disease
    - Roux en Y bypass and sleeve gastrectomy appear best procedures for weight loss
      - Appropriate patient selection continues to be critical
- Physical activity
  - Any increase in physical activity is beneficial but current recommendations for non-pregnant adults are:
    - 150 minutes of moderate to high intensity aerobic exercise per week spread over ≥ 3 days each week and no more than 2 consecutive days without exercise
    - At least 2 sessions of resistance exercise at low to moderate intensity per week
    - Sitting for < 30 minutes at a time
    - NB: The intensity and duration of the exercise may need to be reduced due to comorbidities such as heart disease and previous stroke etc. Ensure safety including adequate footwear if increased foot risk e.g. peripheral vascular disease. Using body weight for resistance exercise can still be effective.
- These recommendations are not realistic for all people with CKM disease, but support should be provided to increase physical activity and movement as much as possible given the significant benefits:
  - A 5 – 6 minute brisk walk a day is associated with an additional 4 years of life
  - Adding 500 steps per day is associated with up to 10% reductions in mortality
  - Moving briskly doing everyday activity is associated with up to 50% reductions in CVD
  - Stretching reduces blood pressure and glucose levels
Healthy sleep
- Sleep disorders are common in people with CKM disease and are associated with weight gain, high glucose levels, high blood pressure, arrhythmias and cardiovascular disease.
  - Obstructive sleep apnoea (OSA) is the most common sleep disorder in CKM syndrome. Treatment of OSA significantly improves metabolic outcomes and reduces CV events.
- Optimal length of sleep for beneficial effects on body weight and CKM disease appears to be 6 – 8 hours every day. Unfortunately ‘catch-up’ sleep does not fully reverse the deleterious effects of insufficient sleep → beware of the risk of CKM disease in shift workers.
- Strongly consider discussing healthy sleep and sleep hygiene, and screening for OSA and other sleeping disorders when appropriate for all people with CKM disease.

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