Medical Nutrition Therapy Recommendations

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Okay, so good afternoon, good evening, everybody. Welcome to this month's EASO comms webinar. We are going to be discussing medical nutrition therapy guidelines today, looking at the adult guidelines, the child guidelines, and also a bit on the methodology.

We have four fantastic speakers with us today. I have dropped all of the speaker bios into the chat, so you can read those at your own leisure, and I will also circulate those following this webinar. And we are recording the session as well, so it will be uploaded to the SharePoint for you all to access and utilize in your spare time.

So we, just before we start as well, Ewan's asked me to remind everybody about the summit in September. So we're going to Istanbul for this year's comms summit, and there is free accommodation for a minimum of one member from each centre on a first-come, first-served basis. So if anybody hasn't registered yet, we'd encourage you to do so and make use of the free place there.

Get in touch if you have any questions or any problems with that, just let me know. Yeah, so we'll pass over to Ellen. So Ellen is a researcher, author.

She is chair of the Netherlands Knowledge Centre of Obesity. She has been working in, excuse me, primary care as a dietician for over 25 years. She has published four books on nutrition and specializes in obesity management.

And as part of the working groups and networks, she stimulates evidence-based treatment of obesity by healthcare professionals and is looking to play a more dominant role for patients in disease management, which I think is fabulous and very important. So Ellen, I'll pass the floor to you to start. Thank you very much, Katie.

I will be replacing Professor Maria Hassapidou because she has been engaged elsewhere and I'm the deputy chair of the ESG and Obesity of IFAD. So we have worked on this project together and this is an online process for many years now that we have been working on to get evidence-based guidelines on obesity, nutritional guidelines, which there's a great need of in Europe because they have not been described as such. And this meeting will bring you to the newest knowledge and the newest methods we have used to gather all this evidence.

So we have worked together with EASO. IFAD is the European Federation of Dietitians and we have worked with EASO in the nutrition working group. And we have run through the stages you see mentioned here, surveys.

We have done surveys in European countries. We've done a systematic literature review and we established two writing groups actually, one for adults and one for children. And we've been writing those guidelines with those groups.

And these guidelines are necessary to provide policymakers and healthcare professionals with a consensus document to be used equally by all member states. And of course, this document is in English and we also have in future the hope that IFAD students will translate those guidelines in the large European languages in the years to come. So our methods have been two surveys.

One survey has been carried out in 2014. And you can see that only nine countries had guidelines then and participated. And the second survey was the last one and that's been done later.

And Antonis Vrasopoulos will talk about that later. And you can see that the green countries had guidelines and the red countries did not. So the aim was to compare available guidelines for the dietetic treatment of obesity.

And the follow-up survey has been carried out through 2016 to 2021. And 13 countries have participated in that one. And also 90 individual dietitians in these countries.

And these elements have all been described in those guidelines. And these elements are from the early guidelines but also from the later guidelines and have resulted in the article that you see as reference on the bottom part here. And you can see that the guidelines do not all describe the same functions.

These details will be given by Antonis Vrasopoulos later on but this is to give you an impression how large the differences are between the guidelines and how great necessity was to have one European guideline to deal with all these subjects once and for all and see what they are meaning in dietetic practice and for patients, of course. The treatment outcomes that have been described as you can see almost all talk about weight loss and you see that five to 15% weight loss is most common. And you can also see that the half of all the answers dealt with the comorbidities, improvement of comorbidities and quality of life but weight loss maintenance is not very common yet.

So there are improvements to be made in the future as you can see. And here you see the differences in what is the goal for weight loss. You can see there's also 16% wants 10% weight loss and 22% want more than 10% weight loss when the BMI is over 35.

So there are big differences in all the aspects of obesity management. So, and a short attention to the anthropometry as you can see height, weight, BMI are measured by everyone, nearly everyone. Waist circumference is only in 60% of the cases measured and bioimpedance as well.

So there are still, there's still room for improvement as you can see here. And you see body composition is only measured in 64% of the cases. So there's a great room for improvements here.

So what we determined as what the guidelines should be, they should be based on the latest available evidence. They should aim to expand on the existing state-of-the-art knowledge and act as a platform for collaboration across countries and regions, be transversal and applicable in all European countries and allow for local adaptation based on the needs and priorities of each country and region in Europe. So this is my short introduction and I'll end here and give the floor to Tamara Brown who will tell you how the evidence has been collected.

Tamara, the floor is yours. Thank you, Ellen. So just while you share your screen Tamara, I'll just give you a brief introduction.

Thank you, Ellen. That was a lovely start. So Dr. Tamara Brown is a Senior Research Fellow in Obesity at Leeds Beckett University in the UK.

She specialises in reviews of behavioural intervention for weight management across the life course, including people at high risk of weight gain and people at vulnerable life points, for example, pregnancy and early years. Tamara is a trained Cochrane systematic reviewer and has authored various reviews and she has held various research fellow posts across the UK universities. She is passionate about patient and public engagement in research and is part of a steering group called Obesity Voices, the details of which I have placed in the chat for you to have a look at.

So Tamara, the floor is yours. Thank you. That's brilliant.

Thank you, Katie. Okay. I don't need to introduce myself.

You've done such an excellent job. So my brief was to develop the methods to underpin these new European guidelines, which were to be based on the latest evidence in medical nutrition therapy for adult obesity. And we decided pretty early on that it would be great if we could use the medical nutrition therapy chapter of the Canadian clinical practice guideline.

We could update, we could undertake a review to update the evidence underpinning that chapter and then help to translate this updated review evidence into the European context and prepare the new European guidelines. So this was to be achieved through collaboration between Obesity Canada, EASO and EFAD. And this, I spent many a long conversation with Jimena and Jennifer and particularly with the MERS team, Donna and Diana, and of course the other Canadian chapter authors, Carol and Carleen.

And without this collaboration, this work just wouldn't have got off the ground. So thank you. Okay.

So I'm just gonna talk briefly about the overview of the methods process of the Canadian guidelines that we used for the new European guidelines. So to start off with, the PICO was developed by the Canadian authors. And this was then used by MERS to create the literature search and screen the articles.

And these were filtered through to the authors of the Canadian guideline who would then appraise the full article. And then it went back to MERS who then graded the articles. The only difference for the new European guideline is that it was MERS rather than the Canadian chapter authors that critically appraised the new evidence.

And I summarized the data and presented to Obesity Canada for the chapter authors to then decide the implications for the existing Canadian guidelines. So you can see the box on the right hand side basically describes the different levels of evidence. And these levels are assigned related to the design of the studies and the number of the studies.

Whilst the grade at the bottom of that box is about how confident we can be in the strength of that evidence to underpin a recommendation. So I'm just gonna talk briefly about the timeline. We started in April, 2021 with conversations with Germaine, Jennifer and myself about how we were going to do this.

MERS ran an update of this literature search in April. They used the original Canadian search and they updated the evidence from November, 2018 through to March, 2021. And this created over 10,000 citations which MERS then screened.

They then, MERS then gave the Canadian chapter authors just over a hundred papers to screen using a program called Distiller. And these 111 papers were whittled down to 56 included articles, which then went back to MERS to critically appraise them. And then since about June last year, we've gone through a synthesis of this new data taking into account the European context and the completion of the European guidelines for submission and I'm just going to talk briefly about the methods of this synthesis before handing over to Germaine.

And then I'll hand over to Antonis. So you can see on the slide here, these were the critical appraisal questions that were asked both for the Canadian evidence and then for the new guidelines. We followed exactly the same critical appraisal process.

We were interested in not just the study design and the number of studies that could underpin a recommendation, but quality assessment of those individual reviews or studies. For example, did the paper report a comprehensive search of the evidence? Did the authors avoid bias in selecting articles? Was there follow-up on 80% of participants? Was there blinding, et cetera? So I'm just going to highlight three of the main methodological challenges in using the Canadian clinical practice guidelines to underpin and update and use to produce new European guidelines. The first of these was, how do we contextualize the recommendations for the European context? And Antonis is going to talk to you further about that in a minute.

And then in terms of updating the literature search, underpinning the Canadian chapter, how were the chapter authors going to decide whether there was enough new evidence to change any of the recommendations? And thirdly, the challenge about how we ensure consistency across the different guidelines. And I'm going to talk to you a little bit more in detail about that. So in terms of consistency, I think there was three issues that we needed to consider.

And that was how we frame medical nutrition therapy. And we wanted to be consistent across the Canadian guidelines and across the new guidelines. In that medical nutrition therapy is an adjunctive therapy alongside behavioral, pharmacological and surgical interventions.

It's not a behavior issue that is only applicable for affecting behavior change because that would fail to acknowledge the biological and pathophysiological disease of obesity. We also wanted to be consistent in how we define obesity. Although increased body fat can have important implications for health and wellbeing, the presence of increased body fat alone does not necessarily imply or reliably predict ill health.

And we also wanted to be aware of the connotations of using different words. So for example, using the word diet and dietary intervention can infer some kind of restriction or deprivation of foods. And so we wanted to be consistent with the Canadian guidelines and their use of terminology such as dietary patterns and nutrition intervention.

And the narrative is important and it reflects decisions made during the process of the guideline development as I'm going to try and explain with my next slide. So the main challenge of all for me in terms of the methods was how do we synthesize this new evidence with the existing recommendations? The new studies that were identified could not be co-synthesized with the previous evidence included in the Canadian guideline. So it was never going to be an update as you would update a systematic review.

And this is because the evidence underpinning the Canadian recommendations is similar to an overview of reviews. It didn't have additional analysis which synthesized individual study data. And data was taken from the highest level of evidence and downgraded if outcomes were limited to weight data.

This downgrading of evidence if limited to weight data reflects the narrative of the Canadian guidelines because what we're really interested in is whether a study was able to use clinical markers to assess for adiposity-based complications beyond BMI alone. Therefore the approach taken to develop the European guidelines was to use the existing guidelines as they stood, grade the quality of the new evidence available and identify areas where there is a potential to strengthen the existing guidelines. And if anyone wants to discuss any of these methodological issues in greater length then my contact details are here.

And thank you very much and I will hand back now. Lovely, thank you very much. So a fantastic introduction overview there.

So we're now gonna pass over to our next speaker. So while you share your slides I'll do a little introduction if that's okay. Yes.

So Antonis has studied nutrition and dietetics in Athens. He then did an MSc and PhD in human nutrition in Glasgow. We were discussing the weather earlier which much nicer in Greece than in Glasgow.

His research interests are focused on understanding the role of nutrition in the prevention of cardiovascular disease with a particular interest in immune system of chronic disease development. He spent three years in the Nestle Research Centre in Switzerland as a postdoctoral researcher studying the role of food policy and promoting healthy behaviours. And he's a research associate in Athens where he participates in the teaching of food and nutrition policy postgraduate course and also holds an honorary research fellowship with the University of Glasgow.

Further details of all of the speakers, like I said are all in the chat, but I will pass the floor to you. Thank you very much. Thank you, Katie.

I have nothing to add other than thanking everyone for the invitation and for the great introduction. So I'm gonna dive a bit deeper on the technical side of what are the current obesity treatment guidelines and what's the situation in Europe. And why do we think that the work that Tamara with MERS organized are now ripe and ready to be launched in Europe? We are very happy to tell you that we think that within the next month, you'll be able to have access to the published paper.

You will be able to see all the evidence and all the studies and critically appraise for yourself the work done. So I'm a member of the ASDN Obesity. Ellen has already mentioned the ASDN Obesity and I'm gonna go through very quickly my introduction.

I think we all know that there are no signs of reduction in obesity. If the issue is still expanding at the lower speed but the change is still upwards. And unfortunately we are going to surpass the 30% prevalence, especially among men by 2035.

So in the next four years with the statistics say that one quarter of Europe will currently be living with obesity and they will be considering obesity interventions. So although prevention is crucial, treatment will be the top of public health priority in most countries. So as Ellen already mentioned, this whole work started in 2014 where AFAD alongside the ASO committed to creating the first European guidelines for obesity.

But it has been a long road because we needed to understand first what are the needs of the European dietitians, review the existing literature and then end up in a consensus document that we can provide policymakers and healthcare professionals with. So I will start with the first study which was a survey that we conducted in December, 2014 as AFAD and we carried out the survey among European dietitians. We asked them to provide us the latest national obesity treatment guidelines.

And we aimed to compare the available guidelines for the dietetic treatment of obesity. In green, you can see the countries analyzed. So the countries that provided us with the guidelines and we also had input from two countries, France and Spain that at the time there were no national guidelines.

So although we did have it out so we didn't receive anything to analyze. As you can see, there are a lot of areas of agreement and a lot of areas of disagreement with the guidelines that were available in 2014. And you can see that all the guidelines were evidence-based and they gave an indication of the level of evidence.

They all considered diet. Most of them considered exercise although here in Greece we issued explicitly guidelines only for the dietary part. But at the time, not all the guidelines considered behavioral or any psychological approaches in treating obesity in adults.

Weight maintenance was mentioned in quite a few countries but then when we went to the more specifics, you can see that at this stage, only three countries provided a clear goal for an energy deficit and only two countries talked about any macronutrients or the composition of the diet. The majority of the studies at the time talked about fat quality or fat reduction depending where country it was coming from. Glycemic index was quite important and the Mediterranean diet was mentioned in Italy but also in Central and Northern countries.

As you can see, meal replacements, and I'm gonna stress the part of meal replacements have already been part of the guidelines even since 2014 in many countries and a weight loss goal was not very well established at that time. So what we saw is that the dietitians actually kind of reflected those guidelines and the dietetic practice reflected this. So we carried out an analysis to see what are the current practices employed by dietitians when dealing with obesity.

We received 195 responses from 22 countries and we saw that most dietitians are a very well-trained profession. A very good proportion of them have postgraduate and doctoral degrees and in Europe in general, private practices and hospitals are the main areas where dietitians are employed. Although as you saw previously, the guidelines do not all state an explicit weight loss goal, the majority of dietitians did follow a specific weight loss goal of 5 to 15% with personalization and half of them mentioned to us that they actually measured the improvement of obesity comorbidities as an outcome in the interventions.

A lot of them were concerned about the quality of life and they tried to measure quality of life improvements, but very, very few, less than 15% actually mentioned that they are actively engaged in weight loss maintenance. If we go back, if you allow me, you will see that weight loss maintenance was not mentioned that much in any of the guidelines. So it doesn't come as a big surprise that dietitians are focused more on the active weight loss phase, but not on the maintenance side.

And when they said 5 to 15% weight loss, some of them said 10%, some of them said 5% and some of them provided us with specific indicators of when would they go above the 10% weight loss and most of them linked this with the starting BMI of their patient. When we asked them how do they assess adiposity and what is the anthropometry used, all of them mentioned BMI, but 60%, which we found to be quite low, mentioned using waist circumference and the same amount of people said that they will be using impedance. In reality, what that showed is that although all of us measure height and weight, we don't all employ other measures of anthropometry.

When we asked them what is the most common diet they prescribed, they all said that they're trying to personalize and a few of them said that they were following a Mediterranean diet and even less were following extreme, not extreme, specialist diets like the low fat, the low carb, or the very low carb diets. When we asked them how they define success, they said that only 30% said that the weight loss quantity is the way that they actually went about to measure their success. 50%, 55% said interestingly that they were interested in body composition, although not that many measured any waist circumference or impedance.

Again, 50% mentioned comorbidities and about 70% said that the long-term adherence to the plan was how they would define success, which to our eyes was a bit contradictory with the fact that they did not really focus on weight loss maintenance or they didn't consider weight loss maintenance as a success point in their intervention. So in this context, the work that Tamara introduced before me started. So we started as an extensive writing group between IASO and EFAD to work on guidelines and based on the literature and based on the evidence that we have at the time, we said that what we need are guidelines that are based on the latest evidence.

We don't need to reinvent the wheel. So we need to expand the existing state-of-the-art knowledge. So if there is already a piece of work that is considered state-of-the-art, we should build on that and we should not start anew.

And we want these guidelines to act as a platform for collaboration across countries and regions. We want them to be transversal and applicable across all Europe. And we also need them to be agile and be able to be adapted locally.

So quickly and after the publication of the Canadian Adult Obesity Clinical Practice Guidelines, we decided that the best way to go forward is to adapt the medical nutrition therapy chapter to the European context and to update the new evidence base with the studies published between 2018 and 2021. So as Tamara already said, MERS carried out a systematic review of the literature between November 2018 and March 2021 and through mBase and OVID. And although they found 42,000 new studies, we ended up with 56 studies that were included in the analysis and really met the criteria that we had set up.

I will briefly show you there that there were specific themes that the literature search was structured against. So we wanted to see what are the new updates on any caloric restriction? Should we have specific aims for that? Are there specific macronutrient recommendations or any considerations of macronutrient quality? The use of micronutrient supplements, the use of low-calorie sweeteners, meal replacements and liquid formula diets, and eating approaches and dietary patterns. When we say eating approaches and dietary patterns, that was the biggest part of the work.

So over there, we could find Mediterranean diets, Nordic diets, or even non-dieting approaches or things like intermittent fasting. So if we start to see what we found, so this 56 studies had 32 randomized controlled trials, 21 systematic reviews and meta-analysis, and two studies that were included, but they reported data from non-randomized trials or cohorts and were already from the beginning graded as level three. The RCTs covered primarily the areas of meal replacements, high protein dietary patterns and meals, time-restricted eating and intermittent fasting, the Mediterranean diet, community interventions.

And then we had single studies in a very large area of interest. So we had vitamin C supplementation, flavonoid supplementation, flaxseed supplementation, paleolithic diets, flexible diets, central European dietary pattern, a combination of Waste-Based Web-Based Interventions or even studies on low calorie sweeteners. When we're moving on to the meta-analysis, the area again, the areas were pretty much the same.

So we see a huge focus on restricted fast and fasting interventions, low carbohydrate dietary patterns, pre- and propiotic supplementation and meal replacements. So, as I said, we started with the idea that those studies will build upon the existing Canadian recommendations. So for those of you who haven't seen it, the Canadian recommendations were among the first that introduced this concept of we're going beyond simple guidance for an intensive lifestyle intervention.

And we consider the whole journey of obesity treatment from the dietitian and the whole healthcare group. So those are guidelines that cover things like weight bias, stigma, quality of life, impact on lifespan. But on this specific guidelines, we only focused on the medical nutrition therapy part.

So under those guidelines, the journey towards weight loss and specifically the treatment of obesity, which could sometimes not even be linked to weight loss, is patient centric. It's created by the patients for the patients with its smart evidence-based goals. And the team of healthcare professionals is there to assist the adult living with obesity through the journey.

I will start by saying which guidelines mentioned in the Canadian guidelines still stand and we have repeated them and we have endorsed them anew in the European guidelines. So we start with what we consider to have high evidence strength recommendations. So we start by saying that every adult living with obesity should receive individualized medical nutrition therapy, ideally provided by a registered dietitian to improve weight outcomes, waist circumference, glycemic control, blood lipids, and blood pressure.

We also have good evidence that the portfolio diet pattern, the dietary approach to stop hypertension and partial meal replacements are very good tools to help in the treatment of obesity. More specifically, the portfolio diet could help improve blood lipids and various targets on blood lipids. And the DASH diet can help reduce body weight and waist circumference.

Partial meal replacements, when we replace one or two meals per day as part of a calorie restricted intervention, also have a really good evidence to reduce body weight, waist circumference, but also on top of that help with blood pressure and improve glycemic control. We have moderate evidence that calorie restricted dietary patterns where we can use variable macronutrient distribution. So dietitians are given the option to adapt the macronutrient distribution to the needs of their patient, either low, moderate, or high carbohydrates.

The evidence is all the same. Can achieve similar body weight reductions over six to 12 months. So there is no need to focus on any specific micronutrient distribution as far as we are on a calorie restricted dietary pattern.

And we also know that the Mediterranean diet can improve glycemic control, triglycerides, and reduce cardiovascular events, even in the absence of any change on body weight or waist circumference. So in patients where we see little motivation or to reduce their weight, the Mediterranean diet could still help with comorbidities. A vegetarian dietary pattern helps reduce body weight and improve glycemic control in blood lipids, and so does a portfolio diet.

Pulses like peas, chickpeas, and lentils can improve body weight, improve glycemic control, and establish lipid targets. Fruits and vegetables are really good in improving diastolic, blood pressure, and glycemic controls. And nuts could be considered when the aim of the intervention is to improve glycemic controls.

Whole grains should be considered when we talk about lipid targets, and a low glycemic index diet should be considered when we want to reduce body weight, glycemic control, and lipids. The Nordic dietary pattern can be used to reduce body weight regain, to improve blood pressure, and intermitted or continuous calorie restrictions achieved similar short-term body weight reduction. I will come back to this in a bit.

Finally, we have low quality evidence that focusing on dairy foods can reduce body weight, or that focusing on nuts can help establish improvements in lipid targets, and the impact of pulses or vegetables or coronary heart disease and cardiovascular mortality. So basically to sum up, what we know is that we need to start focusing on what our patient needs, and to see whether body weight or body composition changes or improvement of comorbidities are the main focus of the intervention. Now, as Tamara mentioned, the new evidence that we found were mainly in the area of partial meal replacements.

So we found five new studies, and we updated the Canadian recommendations by saying that partial meal replacements are indeed helpful to reduce body weight and waist circumference, and improve blood pressure, improve glycemic control. There is no aim to change the current evidence level, and we should consider that the new literature, it builds up on the previous evidence. On the contrary, when we talk about intermittent or continuous calorie restrictions, we stand with the wording of the Canadian recommendations that they achieve similar short-term body weight reduction.

And when we say they achieved similar short-term body weight reduction, if we say it explicitly, we do not see any evidence of superiority. So we think that we saw that a lot of new evidence is pointing towards potentially negative impacts or no impact of intermittent fasting versus continuous calorie restriction. And we think that we should treat it cautiously until we wait for the latest evidence to actually come out and to have a better idea of what the literature is suggesting.

What we think it's very important is that even the literature that we found, and even the research doesn't focus on maintenance as much as we think it should be. And all the studies focus more on the active weight loss phase and doesn't help us guide our patients a lot through the weight maintenance journey. And we also think that it's very important, especially for European dietitians to highlight that waist circumference should be measured in all individuals with a BMI between 25 and 35.

BMI alone is not an adequate measure to assess a deposity, and we shouldn't focus on that only. So we further strengthen the Canadian guidelines and we say that it should be a priority for European dietitians to have a greater focus on waist circumference measurements. And we also think that it's very, very important to start talking about considering stigma and bias within our healthcare community.

And I'm gonna link that briefly to the issue of circumferences, because one could think that the reason we're not using circumferences is because our patients or even ourselves are more conscious with stigma or internalized bias, because circumferences are greater link to body image perceptions. And we should use these circumferences to help our patients and to help ourselves in transforming themselves and being more comfortable with their body image perception. It's also a great tool for self-assessment and we should re-educate our patients that when we measure circumference is not a moment of shame and it's not a moment of judgment, it's actually an empowering moment.

Finally, we think that it's very important for European dietitians to start being a bit more confident on analyzing through nutritional assessment, the background diet that their patient is more comfortable with. So we saw that there are many, many different options that more or less are equally applicable when we treat people living with obesity. So instead of coming with our own preconceptions of what is the best diet for them, we should spend a bit more time and we should utilize tools like the FFQs or the Mediterranean diet score or the Nordic diet scores and try to understand whether our patient is already following a traditional dietary pattern.

In Europe, we have a very clear distribution of the traditional dietary patterns and we should aim to embrace them and to help our patients through their weight loss journey by sticking and increasing their adherence to the traditional diets. So we need to start focusing more on the tools where we assess our patients rather than coming with our own conceptions and re-educating our consumers to our patients to something that might be very far away from what they're currently eating. Now, the current guidelines, we are aware that ask dieticians to be prepared and familiar with more than 10 different nutrition interventions.

There is a big focus on behavior interventions and we do think that there is a good opportunity for us to ask for an update on the nutrition and dietetics curriculum. We need as part of the guidelines implementation to talk about new research and education and we need to provide dietitians with the skills to be familiar. A message to all of you is don't feel that you do not have the skills to apply any of those things.

Don't be afraid, rather see it as an opportunity to help train yourselves in new skills, in new dietary patterns and try to see how you could actually use them in your daily practice. As we said, we are currently mapping the latest recommendations up to 2021 to see gaps and similarities with the current recommendations that we're about to issue for Europe to allow for local implementations and to identify gaps. And we are always building our European network of obesity dietitians and you can find us on Facebook.

Thank you very much. Fabulous, thank you very much. Another fantastic presentation.

So we are going to move on to our last speaker now. So I'll just let you share your slides while I do your introduction. And if there are any questions from anybody listening then please do drop them in the chat and we will put them to the speakers at the end or we can have a discussion about everything that we've been presented with today.

So Odisei is an Associate Professor in Clinical Nutrition and Dietetics. He has published 115 scientific papers in peer-reviewed scientific journals and over a hundred post-presentations. He's a member of the editorial board and evaluator in scientific journals, international conferences and research proposals.

He has supported the Ministry of Health of Malta and the National Institute of Health of Estonia in the implementation of obesity prevention programmes. And his scientific work has received a national and international awards details of which can be found in the chat. So I will pass the floor to you and our final presentation this afternoon.

Thank you very much. Thank you very much for your introduction and for the invitation in this very interesting webinar. Happy to contribute to that and be able to interact mostly with members of the Azure.

So while moving to my presentation, as Tamara said, obesity is defined by excessive adiposity and can impair health. And we know that in 99 cases, percent of cases, obesity is attributed to factors that have to do with energy imbalance. So when energy intake exceeds energy expenditure.

In this model, we can see. Sorry to interrupt. Can I just get you to pop your slides into presenter mode just so they'll come up a bit bigger on the screen and so we can see them a bit better.

I think it's already in presentation mode. Well, I can see all of the slides rather than just the one that you're talking about. Okay, I will do that again, no problem.

Thank you. Just makes it easier for us to read and see. Yes, of course.

Is that okay now? It's just loading for me. Yeah, I'm not sure we can see all of the individual slides. I'm not sure if we can make them bigger in any way.

Okay. Is it okay now? Yeah, it's better, but it's still not in presenter mode. I can't see on the screen where to recommend, but if anybody else can give us a hand.

If not, we'll have to leave it like that. That's better than it was before. Yeah, do you wanna go ahead like that? Thank you.

Is it okay now? Yeah, it's better, thank you. Is it full screen? No, it's still not full screen on my side. Yeah, it is with me.

That looks much better. Okay, we'll leave it like that. Carry on.

Oh, there we go. Yeah, it's gone now. It must just have been slow on my side, sorry.

Continue, thank you. Okay. Okay, I will speed up.

So this model actually depicts the determinants of childhood obesity, including the risk of obesity. Several factors that have to do with the socioeconomic background of children and their families, parental styles, parental behaviors, and factors from the social environment of children, and factors that have to do with individual characteristics like age and gender. So we know that childhood obesity is multifactorial.

And that it affects a high number of children and adolescents globally. Based on the WHO estimations, 39 million cases of children under the age of five were living with overweight or obesity in 2020, and more than 340 million cases of children, adolescents five to 19 years had overweight or obesity in 2016. And specifically in the WHO European region, it is estimated that one out of three 11 year old children lives with overweight or obesity.

So these figures are alarming, not only because childhood obesity directly impairs children's and adolescent's health, but also because the literature shows, evidence shows that a very large number of children, adolescents, are living with overweight or obesity. We have excessive body weight in adulthood. And this is linked to the development of obesity related densities like hypertension, type of diabetes, cardiovascular disease, et cetera.

So it can be concluded, understood that childhood and adolescence is a critical time window and a great opportunity for early interventions to prevent or treat obesity. In line with that in 2015, the Childhood Obesity Task Force of EASO has published this position paper and suggested that the classification of obesity as a chronic disease in children and adolescents would first of all, increase individual and societal awareness, would improve early diagnosis and intervention and lead to the development of new approaches to prevent or treat obesity. So far, countries have established their own approaches to identify, to screen children and identify those who are living with overweight or obesity and develop their treatment procedures.

A common basis of all these approaches is that they rely on lifestyle modifications, behavioral change regarding diet, nutrition, physical activity and sedentary behaviors. They're also underpinned by the first do no harm approach and philosophy and are in line with national, local health rules and weight management guidelines. In the UK in 2014, the National Institutes for Health and Care Excellence published some guidelines for the identification and specific lifestyle management service pathway for those who are living with overweight and obesity.

And in 2019, the National Health Service initiated some services for children with obesity related complications so that they could receive specialist treatment and tailored health care in line with UNESCO recommendations. In the scientific literature, we can identify two important reviews which have focused on weight management and specifically dietary management approaches. The evidence included in both of these reviews relies on clinical practice guidelines which were based on empirical evidence, published guidelines and were informed by clinical expertise and expert opinion.

The systematic review and meta-analysis of Doug Hanson and colleagues proposed a structured framework to guide dietary intervention whereas Holman and colleagues focused on dietary management of obesity and included another component on severe obesity in young age groups. Both of these reviews have substantially the formation of guidelines and of course guided so far the healthcare professionals for the treatment of obesity in Europe regarding children and adolescents. But of course, there are many more RCTs that have been published after these two reviews were published.

So it is essential to inform the clinicians, health professionals with updated high quality and more detailed guidelines so that these healthcare professionals can guide with individualized, personalized approaches and age appropriate approaches the medical nutrition therapy in children and adolescents. To cover these gaps, the position paper on medical nutrition therapy for children and adolescents living with overweight and obesity is currently being developed in collaboration between IASO and the European Federation of Dieticians specifically with ADHD and obesity. So this position paper will be published in the coming months, includes synthesized graded evidence from interventions that were published, update and of course it was a prerequisite that this intervention had the dietary component and time to treat overweight or obesity in children and adolescents.

Then we also applied an expert consensus to develop recommendations for individual medical nutrition therapy and the coming slides I will present with you some of these important recommendations but also some conclusions that do not necessarily consist recommendations but I think are worthwhile mentioning. So one of these conclusions is that there's a large number of studies that we identified that was focusing on obesity, not overweight. And this is to our opinion, a significant finding because this means that children are not very identified and cannot be treated as soon as they are identified and cannot be treated and with evidence-based interventions and improve their health outcomes.

So moving to the recommendations now, the first recommendation which are general recommendations that obesity as a chronic disease be treated with both intensive and long-term care strategies. So in combination of that leads to the better health outcomes. Also the focus of obesity management should be oriented towards improving patient-centered health outcomes rather than weight maintenance or loss alone.

So this is something important for this age group since now we have the understanding there might be metabolic complications that need to be improved and we need to have a full screening of young patients and lead into the improvement of his weight status and health outcomes. Also long-term and regular medical nutrition therapy can result in the maintenance of energy deficits that reduce adiposity indicators in children and adolescents with overweight or obesity while maintaining nutritional requirements for growth. Of course, we need to keep in mind that a young patient who is living with obesity is also a person, an individual who has further requirements for optimizing his growth and development.

So of course, we know that in this age groups, the physical activity levels are higher compared to adulthood. So these requirements, their energy requirements need to periodically be assessed, reviewed, adjusted so that the energy deficit is retained and the literature shows that this can happen for one year and lead to very good health outcomes. It is also recommended that individual medical nutrition therapy is focused on reduced energy density through increased vegetable consumption, fruit intake, and limited fruit juice consumption.

There are some findings regarding the modification also of the macronutrient proportions in the diet. However, it's not well justified that we should aim for reducing or increasing any of these three macronutrient protein, fat, carbohydrates. The principle idea is to focus on fruits and specifically promote, as we said, fruit, vegetable.

We can see that increasing their intakes by 0.5 to 1.5 servings per day and maintaining these changes for one year is feasible and can lead to significant weight loss. As we will see in one of the next slides, limiting the fruit juice consumption is also crucial because a large number of children, adolescents tend to over-consume these foods. Last but not least, all the dietary interventions need to be personalized, tailored to the individual and its family.

So this procedure certainly starts with a very extensive nutritional assessment. Gather the information that we need, be able to understand the individual that we have in front of us, have a full idea of the socioeconomic background and tailor not only the dietary plan, but also the whole dietary intervention to the needs of the child, adolescent and its family. And of course, be able to record the barriers towards improving the lifestyle behaviors and finding practical collaboration with the family in this process.

The sixth recommendation indicates that the therapeutic environment of individual medical nutrition therapy supports healthcare professionals with a unique and important opportunity to mitigate psychological, social and physical health consequences of over-obesity, including weight bias and stigmatization. Also, role modeling appropriate non-stigmatizing person first language in a safe, welcoming environment to an optimal clinical care. Some other tools and approaches that are highlighted and are recommended for future interventions is that we should aim to combine clinic and home interventions, involve the whole family, but this again, age specific, certainly include the whole family for younger age groups and move towards a more individual approach to work mainly with the adolescent in this age group.

Also, we identified that using e-health and mHealth solutions might be another useful tool to improve the effectiveness of the dietary interventions. And certainly use tools like motivational interviewing, behavioral change techniques, and possibly expand the duration of the intervention, aim for higher intensity of interventions and use more specialized dietetic skills to lead to a better health outcomes. So these were the main recommendations that came out from our study.

However, I have devoted some time and slides about some issues that we need to consider for the future. Of course, it's essential to have an update set of guidelines, but another thing is how we can implement them in practice. So what the evidence shows, first of all, is that so far a large number of children, adolescents do not meet the food-based guidelines.

Here we can see the example of the TOEI book study, a large European study in preschool children, which was implemented in six countries. And it showed that both boys and girls, normal weight and overweight children, tended to not to meet the food-based guidelines, the European food-based guidelines. I have marked in red those recommendations that boys or girls with overweight and obesity tend to adhere less compared to their normal weight peers.

And here we can see that soft drink consumption for both genders, sugar consumption for boys, vegetables and unhealthy snacking are some unhealthy behaviors that are adopted mainly by boys, preschool boys with overweight or obesity and children and girls with overweight or obesity in Europe also tend to skip the recommendation of daily breakfast consumption. In another similar study that we did in Greece and focus only on children and adolescents living with overweight and obesity, we recorded that the volunteers did not meet any of the recommendations for the core foods with the exemption of meat where they exceeded the recommendations. On the other hand, they tended to over-consume very frequently unhealthy snacks and foods like chocolate, biscuits, soda snacks, et cetera.

To improve the adherence to the guidelines and to the weight management guidelines, it's essential to focus on a multi-level approach. So first of all, it's very important as Antonis also mentioned for adults to establish an early screening procedure for the general population to be able to identify as early as possible in life, those children who are living with overweight and obesity and if possible, those who might still have normal weight status, but have already adopted to a large extent unhealthy behaviors. Possibly this procedure could be applied through the school setting.

Also it's important to implement the weight management guidelines in specialized areas in a discreet manner by well-trained personnel. And then at the first step to broaden our interventions and implement these food-based guidelines at home communities to expand this intervention to broader areas and actually support all children, in our case, those who are living with overweight and obesity to make it easy for them to adopt a healthy lifestyle. Regarding weight management in the areas, the specifically designed areas, private offices, clinics, et cetera, it's essential to train the healthcare professionals, standardize the procedures and methods to treat obesity, screen individuals and certainly use evidence-based recommendations.

And here we can see, for example, the toolkit that was created by Australian colleagues that provides accurate information about the screening procedures. We also need to rely on evidence and learn from stakeholders, such as this study, which showed that the Ministry of Health and Ministry of Education are the two main sectors that are adopting the food-based recommendations. So the stakeholders themselves suggest that we need to expand our intervention with school settings, which is not new.

We know that the school setting can provide opportunities to and supportive environments to promote health eating, promote peer modeling, control modeling by the teachers. So it's essential that we have this expanded intervention in the school settings as well. Possibly use mass media, social media, especially for older age groups like adolescents to make it more appealing as an approach for them and better implementation of recommendations into existing programs and promote activities at community level like food demonstrations.

We also need to keep in mind that there are certain identified barriers in the implementation of these guidelines like the lack of resources, collaboration among centers, conflicting interest, or even people's attitudes like the lack of interest. We know, for example, that in health promotion programs, those who are living with overweight and obesity tend to participate less. We need to take this into account.

And we also need to consider the recommendations of the Food and Agriculture Organization and WHO regarding the techniques and procedures that need to be considered when implementing these guidelines. We need to be clear from the very beginning which foods we need to give as examples and pictures, how to communicate the health messages, and how to make it more easy for the families and the individuals living with overweight and obesity to adopt the health messages and promote this lifestyle modification. And I will close with this slide.

I think it is also very important to keep in mind that we need to ensure equitable access to all these interventions and tackling disparities that are related to educational status, ethnicity, and family income, because the evidence shows that these factors lead to lower compliance and increased dropout from the intervention. Thank you very much. Lovely, thank you very much.

So four fantastic speakers there. Thank you all again for your time and taking part. We now have chance for some discussion.

So we've got one question in the chat from Cathy. That might be a good place to start. I'm not sure which speaker would like to take that, but her question is, will the updated guidelines recommend specific dietary scores and or dietary assessment tools for dieticians to use with people living with obesity? I suggest, Antonis, you will answer that question.

I think I'll answer this. No, we won't suggest any specific scores. The thing is that there are many out there, and we think that at this stage, it's not the place of the guidelines, because once it's in a guideline, it's set in stone and scores might change, and new validated scores might come along.

But it's definitely a thought on the implementation and promotion of the guidelines. So with the national contact points, we would like to focus on what are the validated scores in its country that are available. But also, one of the reasons we won't give that is because people often come with preconceptions also on that concept.

So most people would think that being a Greek, you would like to follow the Mediterranean diet. So they would intrinsically go and give you a MET diet score, which might not be the case. What we're saying is you need to take a back step and assess and help your patient.

So I might be Greek, but a DAS diet might be actually closer to how I eat today. I might not be able to describe this to you, but if you do a thorough nutritional assessment with FFQs and keep an open mind, you might find that it's actually a different diet, that it's better for me. So we want to help, but I think the biggest innovation that the Canadian guidelines introduced that we're trying to keep is this idea that the dietician doesn't know the best way.

The dietician knows many ways and the patient knows the best way for them to achieve their goal. So my question would be personalized care. We've talked a lot about the importance of personalized care, but do you think that would make outcomes more difficult to measure? You know, when you did the sliders sort of across countries about those that ask about BMI, those that do this, those that do that, if we're pushing personalized care, do we think that might make it more difficult to compare services if everybody's doing what's right for the patient? Does that make sense? It makes a lot of sense and it's a big discussions we have because every time we ask personalized care, people say yes, and then you're thinking, what does that actually mean? Because it can mean a million of things.

We haven't concluded yet, but the studies mainly focus on an intervention and you follow this intervention and then it's closed and you change. And I think to my humble opinion, the rest could chip in and say if I'm wrong, you know, as dieticians sometimes are very, are too agile. So we start with a dietary regime and then we see that our patient might not be sticking very well and we're very ready to change and personalize it and, you know, change it.

I don't think it works educationally very well. We need to accept and to educate also our patients that it's gonna have ups and downs, that at some point this regime will not be good for you. You'll be bored of it and you'll come back to it.

And that's the process of the disease itself. Changing dietary regimes every time is not really educating the patient on the life course of the disease. It's giving them the impression that it's the diet's fault.

It's someone's fault. Can I just jump in, Antonis? I think that patients, they need to take that journey with you and you need to make decisions together. And along the journey, the patient learns a lot about himself and about his body and about how he deals with things because it's a learning process for the patient as well.

So, and I think that dieticians should be open to all those developments in the patients and help them to discover these things and make next steps and grow. I think yes and no, because if we are very evidence-based, all the evidence that we have have a certain timeframe. So we need to tell to our patient that when we say that the diet works, the studies have four to six or eight weeks.

So you need to stick to it for six or eight weeks, like the studies say, and then if it doesn't work for you, then we can change it because we don't have studies that say that it works in two weeks. So all the evidence that we're saying now, if I'm changing halfway through after a month, I have- You need at least six months to really- It's a matter of personalization, but over time, because we have no evidence for short-term continuous- No. Changes.

I don't think in overweight and obesity, short-term works. You need at least an intervention of half a year and preferably a year. And the interventions that are funded now in the Netherlands, they even last intensive phases, one year, and then you have a one-year follow-up.

And- So I think in that- I hope that will result in good results, but I'm not sure, but that is what we're aiming at right now. Oh, yeah. I think in that concept, personalization exists, but we need to communicate clearly to our patient that personalization doesn't come every week or every month.

We start the cycle of an intervention which lasts four months, six months. And when this cycle closes, we can repersonalize and we can try something new. And the guidelines do say that, you know, in the maintenance phase, maybe we can change to non-dieting approaches.

But that actually means that I have completed a complete cycle of one intervention. So we don't say personalization throughout. We say personalization in the fact that when you're living with obesity, you might be seeing your dietician over a period of many years, not continuously, but you might go back and forth.

And we have many things that we can do, but not readily. And it's not agility that's the message on personalization. It's more what we said on the scores.

It's not saying that the latest evidence says that, you know, intermittent fasting is good. So we prescribe intermittent fasting to everyone. That's the element of personalization.

I have 10, 11 different interventions. I need to be comfortable with most of them. And if I'm not comfortable, know colleagues that are comfortable and then refer them to the right person to say, you know, I cannot help you with this dietary regimen, but I know someone who can, and you might want to try this with them.

That's my perception of personalization. Yeah. And I guess it's timing for the patient as well, isn't it? Like you touched on some of the services having a psychological element.

Some patients might need that before, some patients might need that after. So again, it's tailoring, I guess, that to suit the patient's needs, isn't it? Yeah. I guess that's where we need to, you know, patient voice is really important in all of this.

I mean, I think that's the element of personalization that some people might need it before, might need it after, might need it alongside the intervention. That's the element of personalization and not really how often I change the diet. I shouldn't change the diet often.

I should follow complete cycles of one dietary regimen, see them through the end and educate my patient that that's actually the journey. You need to see it to the end and I'm here to help you, but you need to see it to the end because you decided you want to try it. I also agree with one exemption, of course, for children, adolescents, that we need to take care of the differentiation that we have regarding their energy needs as they grow up.

So for adults, I am totally in line with adolescents and I would also like to add this for children, adolescents. Well, I still think we need to look at patients at an individual level, because if you have elderly patients and they can be very obese as well, like over 60, we need to be aware that we have to prevent sarcopenia. So we need to be aware of the person that's sitting in front of us and we need to give the really personalized advice and care and management.

Yeah, I agree. I mean, I think the element of personalization doesn't go back to the regimen I will give. It really goes back to how thorough I will be throughout the course in assessment.

That's the key for personalization. I need to assess, assess, assess, assess, assess. I know.

And be able to deliver. There's one thing I would like to answer to Katie's question about assessment tools. I think they can be a next step where we can be working on in the ESDN because we will be working on an infertorial in the future.

So maybe we will have tools also to share between countries and see how we can improve management. Hey, Kathy. There you are.

Sorry, I had my video off. That was great. Thank you very much.

Just going back to the assessment and what you were talking about, Ellen, one of the things we're looking at for the Irish adaptation of that chapter is suggesting that dieticians use nutrition care process and adapting one of the proformas that we use here in Ireland without being very, very specific, but some adaptations for maybe if you're dealing with a population living with obesity. I'm just wondering, is that something you looked at in the assessment? Because I totally agree with you. I think it's like a thorough assessment is probably what drives the quality of the intervention than whatever it is we're trying to deliver.

So I can answer that. So we haven't looked in that in great detail in the sense that because exactly we think that the Canadians have dedicated full chapters to this, we felt that it's a bit too much and we didn't want to rewrite the book. We wanted to adapt the book for Europe and have a reference to say, you know, you can look back to these, those are the new things.

And those are the specific considerations for Europe. So, you know, in Canada, they have considerations for indigenous people. That's not such a big issue in Europe, but in Europe we have other, you know, culture, much larger cultural differences, even within the same country.

You need to consider in some places immigrants, you need to consider other things. And we didn't, you know, try to rewrite the assessment thinking that, you know, a reference back to the nutritional assessment as it is in the Canadian guidelines is enough, but stressing out that, you know, we cannot go with a fixed mindset and that's linked to our data also. I think most of us, dieticians are very well trained in prescribing diets, doing dietary plans, doing the intervention, but we get caught up in the day-to-day job and our biases, I don't know what, it can be professional bias in the sense that I've seen it work and I believe in it and I'm comfortable with it.

And we don't take a step back and the assessment is the time to take a step back and listen rather than talk. Yeah, totally agree. Thank you.

I've just shared the link for the Canadian guidelines if anybody would like to have a look. I think one thing I took, I worked in a tier three weight management service previously with bariatric surgery patients. So one thing I definitely need to read as homework is the guidance they've done specifically on surgery.

Because I think, you know, that in itself, you can have patients who may qualify for surgery, but again, it doesn't mean that is what they would choose for themselves or is what's, you know, the best course of action for them. And one question I've got, which is probably UK specific, and I don't know how relevant this is, but just from my own personal experience, I've worked in services where it's not dieticians that are leading that care with patients. And I wasn't sure how you guys feel about that.

Obviously, whether they were not included in this review because of that reason. Well, it's not UK specific, I have to say. It's a general issue.

So the guidelines say, and we stress this, that the dietician should be the lead. And okay, we have to accept that when available, because we're not readily available in all conditions. That creates an issue sometimes.

But again, I know I'm being a bit, you know, I'm repeating myself. There is a notion that, you know, you can prescribe a diet and you can give an energy deficit. And those are things that are easy to replicate, easy to do, the guidance is out there.

The personalization part is the difficult part. And if we even educate healthcare professionals that they do need us and they do need us to take the lead is exactly this, that it's such a complicated assessment in personalization that you don't want to go through three or four years training just to understand what works best. You can apply multiple things because the guidelines are out there.

You can give the guidance and you can be trained or you can do meal replacements, which are pretty easy to prescribe if we're being very honest. And the evidence says that they're effective. But again, it's more on dealing with the patient themselves that we have a great value.

And it's really not UK specific. And we really need, even as a FAD, and we want to stress out that, you know, the dietitian is part of the healthcare environment, but the medical nutrition part is really something that we should own and lead and we should be trusted to own and lead. Are there any other questions? Anything else that any of the speakers think is relevant to mention? I think we've covered a lot already.

We probably could talk about this for hours, couldn't we? Deathly silence. I'm going to take that as a no. But I think I've probably kept you for enough time this evening.

So thank you again to our four fantastic speakers. It's been a brilliant webinar. I will end the recording.