Consensus on Medical Nutrition Therapy for Diabesity (CoMeND) in Adults: A South Asian Perspective

Figures & data

Table 1 Diabetes and Obesity Burden in South Asia

Diabetes Estimates (20–79 Years)	India	Pakistan	Bangladesh	Myanmar	Sri Lanka	Afghanistan	Nepal	Bhutan
People with diabetes, in 1,000s	77,005.6	19,369.8	8,372.2	1,282.7	1,232.8	1,090.8	696.9	46.0
Deaths attributable to diabetes	1,010,262.1	158,973.7	109,857.3	31,288.3	15,459.1	18,630.3	11,678.9	326.7
Total diabetes-related health expenditure, USD million	7,057.4	1,612.8	535.0	235.2	244.4	182.7	56.0	7.6
Obesity burden in South Asia	Burden varies by state and socioeconomic factors. Percentage of men/women who are overweight/obese as per National Family Health Survey (NHFS)-3 (2005–2006): 30.3% men and 37.5% women in Punjab (North); 24.3% men and 34% women in Kerala NHFS-4 (2015–2016): >15% of adults were overweight/obese in 19 states; of these, in 6 states >25%of adults were overweight/obese^Citation8,Citation83,Citation84	BMI >30 was seen in 30.5% of population; Obesity in women (56.7%) and obesity in men (43.3%)^Citation85	Prevalence of overweight and obesity in urban women was 34%^Citation86	Overweight: 20.6% males and 29.96% females Obesity: 4.77% in males and 10.35% in females^Citation87	Global BMI vs Asian cut-offs: underweight (7.7% vs 7.7%), normal weight (39.6% vs 26.8%), overweight (37.0% vs 34.3%) and obesity (15.8% vs.31.2%). The community prevalence for abdominal obesity was 58.1% when using Asian cut-offs.^Citation88	2016: 36.9% of adults: male: 32.7% and female: 41.2%^Citation89 2020: Overweight: 19%, general obesity: 33.7% and abdominal obesity: 57.1%^Citation90	Nation-wide 2016 survey (overweight/obesity): women 32.87% and men 28.77%^Citation91	WHO 2016 data: Overweight: 24.8%, obese: 5.9%^Citation92 According to a 2018 report, one-third of the Bhutan population is overweight (33%)^Citation93,Citation94

Notes: Data from International DiabetesFederation.³

Table 2 Body Mass Index (BMI) Criteria for Obesity in Adults

Category	Asian^Citation37,Citation38	WHO^Citation37
Underweight	<18.5	<18.5
Normal weight	18.5–22.9	18.5–24.9
Overweight	23–24.9	25.0–29.9
Obesity Grade I	25–29.9 kg/m^2	30.0–34.9
Obesity Grade II	30–34.9 kg/m^2	35.0–39.9
Obesity Grade III	>35 kg/m2	≥40

Table 3 The 4 Ms of Diabesity Assessment

Metabolic	Mechanical	Mental	Monetary
Type 2 diabetes mellitus	Sleep apnea	Cognition	Education
Dyslipidemia	Osteoarthritis	Depression	Employment
Hypertension	Chronic pain	Attention deficit	Income
Gout	Reflux disease	Addiction	Disability
Fatty liver	Incontinence	Psychosis	Insurance
Gall stones	Thrombosis	Eating disorder	Benefits
Polycystic ovarian syndrome	Intertrigo	Trauma	Bariatric supplies
Malignancy	Plantar fasciitis	Insomnia	Weight loss programs

Notes:Data from Kapoor et al.³⁰

Figure 1 Root causes of diabesity.

Notes: Data from Kapoor et al.³⁰

Table 4 Parameters Used to Define Obesity in South Asians

Parameter Studied	Criteria for Overweight/Obesity
Body mass index	>23 kg/m^2
Waist circumference	>90 cm in men and >80 cm in women
Waist:hip ratio	0.9 in men and 0.8 in women
Body fat percentage*	>25% in men and >30% in women

Notes: *As measured by dual energy x-ray absorptiometry (DEXA) scan. Data from Thomas et al.³⁸

Table 5 SECURED Model

S	Severity of obesity	Body mass index, waist circumference
E	Expected prognosis	Expected life span
C	Comorbid conditions	Metabolic, mechanical and mood disturbances
U	Urgency of control	Biomedical or psychosocial issues that require early weight control
R	Risk of complications	Risk of malnutrition, gall stones, other complications due to rapid weight loss
E	Environmental factors	Socioeconomic factors influencing life with obesity
D	Dysfunction and disability	Biopsychosocial dysfunction and disability due to obesity

Notes: Data from Kalra et al.⁴⁴

Table 6 Edmonton Obesity Staging System (EOSS)

EOSS Stage	Level of Obesity and Complications	Biochemical Parameters	Level of Prevention	Intervention
0	No apparent obesity-related risk factors, symptoms, psychopathology, limitations, and/or well-being impairments	No EOSS factors reported	Primordial/No intervention	Healthy lifestyle to be encouraged
1	Subclinical obesity risk factors, physical symptoms, psychopathology, functional limitations, and/or well-being impairment is mild	Any of the following: i) Fasting glucose ≥ 100 mg/dL (ii) Cholesterol ≥ 200 mg/dL (iii) Triglycerides ≥ 150 mg/dL (iv) HDL ≤ 60 mg/dL (v) Fasting LDL ≥ 100 mg/dL (vi) SBP ≥ 130 mmHg (vii) DBP ≥ 85 mmHg	Primordial	Lifestyle modification
2	Established obesity, moderate limitations in activities of daily living, and/or well-being	Any of the following: (i) Fasting glucose ≥ 124 mg/dL (ii) Diagnosed with T2DM or on T2DM medication (iii) Total cholesterol ≥ 240 mg/dL (iv) Triglycerides ≥ 195 mg/dL (v) HDL <40 mg/dL (men) and <50 mg/dL in women (vi) LDL ≥ 160 mg/dL (vii) Diagnosed hypercholesterolaemia or hyperlipidaemia or hyperlipidaemia or on medication for it (viii) SBP ≥ 140 mmHg (ix) DBP ≥ 90 mmHg (x) Diagnosed hypertension or hypertension medication (xi) Any of the following comorbidities: Sleep apnea, gout, arthritis, anxiety, atherosclerosis, fatty liver, congestive heart failure medication, depression, on blood thinners	Primary	Behavioral therapy with supportive medication therapy for biochemical abnormalities and comorbidities
3	Established end-organ damage, significant psychopathology, significant functional limitations, and/or well-being impairment	Any of the following: (i) Angina (ii) Heart attack (iii) Heart failure (iv) Thrombosis (v) Coronary artery disease (vi) Coronary obstructive pulmonary disease (vii) Dyspnea (viii) Exercise dyspnea (ix) Coronary artery bypass surgery (x) Stroke	Secondary	Medical therapy/Surgery
4	Severe (potentially end-stage) disabilities from obesity-related chronic diseases, disabling psychopathology, functional limitations, and/or well-being impairment	No data available to evaluate this stage	Tertiary	Bariatric surgery

Notes: Data from these studies.^44,95,96

Abbreviations: DBP, diastolic blood pressure; HDL, high-density lipoprotein; LDL, low-density lipoprotein; SBP, systolic blood pressure; T2DM, type 2 diabetes mellitus.

Table 7 Cardiometabolic Disease Staging (CMDS)

Stage	Descriptor	Criteria	Level of Prevention	Intervention
0	Metabolically healthy	No risk factors	Primordial/No intervention	Healthy lifestyle to be encouraged
1	One or two risk factors	Have one or two of the following risk factors: High waist circumference (≥80 cm in South Asian women and ≥90 cm in South Asian men) Elevated blood pressure (systolic ≥130 mmHg and/or diastolic ≥85 mmHg) or on antihypertensive medication Reduced serum HDL cholesterol (< 40 mg/dL in men; <50 mg/dL in women) Elevated fasting serum triglycerides (≥150 mg/dL)	Primordial	Lifestyle modification
2	Metabolic syndrome or prediabetes	Have only one of the following three conditions in isolation: Metabolic syndrome based on three or more of four risk factors: high waist circumference, elevated blood pressure, reduced HDL-C, and elevated triglycerides Impaired fasting glucose (fasting glucose ≥100 mg/dL) Impaired glucose tolerance (2-h glucose ≥140 mg/dL)	Primary	Behavioral therapy with supportive medication therapy for biochemical abnormalities and comorbidities
3	Metabolic syndrome and prediabetes	Have any two of the following three conditions: Metabolic syndrome IFG IGT	Secondary	Medical therapy/Surgery
4	T2DM and/or CVD	Have T2DM and/or CVD: T2DM (fasting glucose ≥126 mg/dL or 2-h glucose ≥200 mg/dL or on antidiabetic therapy) Active CVD (angina pectoris, or status after a CVD event such as acute coronary artery syndrome, stent placement, coronary artery bypass, thrombotic stroke, nontraumatic amputation due to peripheral vascular disease)	Tertiary	Bariatric surgery if medically fit

Notes:Data from these studies.^44,97

Abbreviations: CVD, cardiovascular disease; HDL-C, high-density lipoprotein cholesterol; IFG, impaired fasting glucose; IGT, impaired glucose tolerance; T2DM, type 2 diabetes mellitus.

Table 8 BMI Cut-Offs for Management of Obesity in South Asians

BMI Asian in kg/m^2	23–24.9 Overweight	25–26.9 Grade I	27–29.9 Grade I	30–34.9 Grade II	≥37.5 Grade III
Therapy
Diet, exercise, behavioral therapy	∏	∏	∏	∏	∏
Pharmacotherapy		∏ if comorbidities	∏	∏	∏
Bariatric surgery				∏ if comorbidities	∏

Notes:Data from these studies.^5,21

Figure 2 Classification of MNT: therapeutic/preventive.

Notes: Data from these studies.^46–48

Figure 3 Classification of MNT: home-made/commercial.

Notes: Data from these studies.^46–48

Figure 4 Classification of MNT: method of use.

Notes: Data from these studies.^46–48

Table 9 Various Types of Diets in Diabesity and Their Advantages and Disadvantages

Type of Diet	Definition	Reported Benefits	Reported Limitations	Comments
Low carbohydrate diet	<26% carbohydrates or <130gm/day^Citation98	Beneficial effect on HbA1c level compared to normal carbohydrate diet; May be beneficial to cardiovascular risk factors, according to summaries of data of triglycerides and HDL-C; Some studies indicated short-term effects on weight loss^Citation99,Citation100	No evidence to show effect on reducing TC and LDL-C; No significant association with weight loss throughout the duration of intervention.^Citation101	Watery and traditional Indian non-starchy vegetables low in carbohydrate (such as salad greens, cauliflower, cucumber, bottle gourd, cabbage, etc); fat from animal foods, oils, butter, and avocado; and protein in the form of meat, poultry, fish, shellfish, eggs, cheese, nuts, and seeds. Avoids starchy and sugary foods such as rice, potatoes, bread, and sweets.^Citation49
Very-low carbohydrate diet	<10% carbohydrates or <20–50 gm/day^Citation98	Decreased body weight, triglycerides and DBP and increased HDL-C. Achieved a greater weight loss than those assigned to a low fat diet^Citation102	Increased LDL.^Citation102 Possible occurrence of diabetic ketoacidosis with SGLT2 inhibitors.^Citation103	Similar to low-carbohydrate pattern but further limits carbohydrate-containing foods, and meals typically derive more than half of calories from fat. Often has a goal of 20–50 g of non-fiber carbohydrate per day to induce nutritional ketosis.^Citation49
Ketogenic diet	No carbohydrates; Avoid excess protein; High fat (>70% of calories)^Citation15,Citation104	Decreased HbA1c and insulin resistance; Improved lipid profile^Citation105	Likely reduction in endurance performance; Long-term impact on weight loss and physical activity remains unknown^Citation105	Lipid profile should be monitored while patient is on this diet and diet adjustments should be made based on the lipid profile.^Citation15
Paleo diet: the 80/20, the autoimmune, the lacto, the Paleolithic vegan and the Paleolithic ketogenic^Citation106	30% carbohydrate; lean protein of 30–35% daily caloric intake; 40% fat; fiber (up to 45–100 g daily) from non-cereal, plant-based sources^Citation106	Rapid weight loss; Liver fat reduction; Reduces inflammation; Improves body microbes; Improved lipid profiles and glucose sensitivities; Prevents T2DM and metabolic syndrome; Improves nutrition density, enhances satiety^Citation106,Citation107	Expensive; Weight loss at 24 months is similar to that achieved by generalized caloric restriction; Side effects; Low calcium intake^Citation106–108	Diet includes natural environmental foods (lean meat, fish, fruits, vegetables, roots, eggs, and nuts) and eliminates grains, legumes and most processed foods so that it resembles the diet followed by human hunter-gatherer ancestors.^Citation106,Citation108
Intermittent fasting (IF)	No food consumed, fasting	Reduction in weight, triglycerides, insulin, adiponectin, SBP, and TC; Lowers risk of CAD; Maintain lean body mass; May be sustainable for long periods of time^Citation107,Citation108	Weight regain if there is non-adherence/non-compliance; Binge eating on non-fasting days; Weight loss at 24 months is similar to that achieved by generalized caloric restriction^Citation107,Citation108	Time-restricted IF: Eating only during certain hours of the day, for example 16 hours fasting and eating during remaining 8 hours Complete IF: Not eating at all on fasting days, for example alternate day fasting, twice a week fasting Modified IF: Eating 20–25% of basal calorie needs on fasting days.^Citation108
Atkins diet	No calorie restriction; Low carbohydrate; Unrestricted protein and fat^Citation108	Reduction in weight, TG, LDL, TC, TC/LDL ratio, LDL/HDL ratio, leptin, and insulin DBP, SBP, CRP, Improved HDL, insulin sensitivity, and adiponectin^Citation108	Weight regain; Poor compliance; Fluctuating LDL^Citation108	Induction phase (2 weeks)= < 20 g/day carbohydrate Weight loss phase: gradually increase carbohydrate by 5 g/day Pre-maintenance phase: 40–100 g/day carbohydrates Maintenance phase: maintain ideal carbohydrate balance^Citation108
Mediterranean diet	50–55% low glycemic load (GL) carbohydrates; 30% fats; 15–20% protein^Citation108	Sustained weight loss; Reduction in waist circumference and BMI; HbA1C reduction; Reduced risk of diabetes and insulin resistance; Triglycerides, leptin, CRP lowered; Risk of major cardiovascular events reduced; Increase in HDL and adiponectin; Improves mental health^Citation109–112	No known limitations	Include more of: Plant-based food; Fish and other seafood; Olive oil as the main dietary fat source of monounsaturated and polyunsaturated fatty acids (MUFA and PUFA) Eat in low to moderation: Dairy products (mainly yogurt and cheese); Wine; <4 eggs/week Low frequency and amount: Red meat Rare: concentrated sugars or honey^Citation49
DASH diet	55% carbohydrates; 27% total fats; 6% saturated fats; 18% protein; fiber: 30 g; cholesterol: 150 mg; potassium: 4,700 mg; calcium: 1,250 mg; magnesium: 500 mg; sodium ≃1500 mg^Citation113	Weight loss; Reduction in waist and hip circumference, hip circumference and percent body fat; Improved muscle strength; Reduction in HbA1c and insulin resistance; Improvement in T2DM; Lowered blood pressure; Increased HDL-cholesterol; Lowered triglycerides (Evert et al 2019; Perry and Guilder 2019^Citation115)	No known limitations	More intake of vegetables (five servings per day), fruits (five meals per day), whole intact grains (seven servings per day), low-fat dairy products (two servings per day), lean meat (fish and poultry) (≤two servings per day), and nuts (2 to 3 times per week) Reduced intake: saturated fat, red meat, sweets, sugar-containing beverages, and sodium.^Citation49,Citation114,Citation115
Low energy diet (LED)/Very low energy diet (VLED)/Very low calorie diet (VLCD)	EASO: 800 kcal/day VLEDs, <800 kcal/day; LEDs, 800–1200 kcal/day^Citation49,Citation116,Citation117	Rapid weight reduction (3–5 months), maintained up to 4 years; 10–15% of body weight can be reduced; T2DM remission possible in overweight and obese^Citation49,Citation116,Citation117	Not suitable for children, adolescents, pregnant or lactating women, hepatic/renal failure, heart disease, T1DM and elderly Possibility of non-adherence, safety issues, risk of eating disorders, high cost, questionable long-term efficacy^Citation49,Citation116,Citation117	Usually formula LED, VLED and VLCD are used as partial or total meal replacement; Combination of 3–4 products may be used per day.^Citation116
Very low calorie ketogenic diet	Type of VLCD with daily energy intake < 800 kcal but marked daily carbohydrate restriction to <30 g/day (≃ 13% of total energy intake); fat ≃ 44% and protein ≃ 43%^Citation118	Rapid weight loss, positive psychology, increase compliance Personalized VLCKD: lean mass saved, abdominal fat mass reduced Preservation of fatty free mass which plays a key role in glucose metabolism Personalized VLCKD: Restoration of metabolic flexibility, resting energy expenditure maintained, and diabetes reversal^Citation17,Citation27,Citation49,Citation118–120	Not suitable for children, adolescents, pregnant or lactating women, hepatic/renal failure, heart disease, T1DM and elderly Short-time therapy (maximum 12 weeks)	The ketogenic period (Phases 1–3): ≃600–800 kcal/day; Average length is 8–12 weeks but can be prolonged until 80–85% of the desired weight loss is reached Phase 1: Four to six protein preparations of high biological value derived from green peas, eggs, soy and whey are allowed along with low-carbohydrate vegetables. Phase 2/3: Lunch or/and dinner) are gradually replaced by natural protein meals (meat/fish/eggs/soy). Carbohydrate re-introduction (Phases 4–6); The daily calorie intake ranges between 800 and 1500 kcal/day Phase 4: Foods with the lowest glycemic index like fruit or dairy products Phase 5: Foods with moderate glycemic index such as legumes Phase 6: Foods with a high glycemic index (bread, pasta and cereals).^Citation118
Vegetarian or vegan	No or minimal animal-based food	Weight loss; HbA1c reduction; Reduced diabetes risk; Lowering of LDL and non–HDL-cholesterol^Citation49	Less acceptability and adherence in non-vegetarians, hence ideal only for vegetarians; Vitamin B12 supplementation may be required; Careful micronutrient planning (zinc, calcium and iron) required, especially in elderly^Citation121,Citation122	Vegan diet can be purely vegan (no food from any animal source included), lactovegan(vegan diet that includes dairy products), eggo-vegan (vegan diet that includes eggs and the Jain diet (vegan diet that does not include onions, garlic, roots and tubers).^Citation121,Citation122

Abbreviations: BMI, body mass index; CAD, coronary artery disease; CRP, C-reactive proteins; DASH, Dietary Approaches to Stop Hypertension; DBP, diastolic blood pressure; EASO, The European Association for the Study of Obesity; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; SGLT2, sodium-glucose transport protein 2; T1DM; type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus; TC, total cholesterol.

Figure 5 Step-wise approach for implementation of MNT.

Notes:Components of medical nutrition therapy. Data from Kapoor et al.⁶⁰

Table 10 Components of MNT: Comparative Analysis of Recommendations by the ADA, RSSDI, ICMR and CoMeND^15,53,61

	ADA	RSSDI	ICMR	CoMeND
Carbohydrates
Recommended intake	ADA does not provide any recommendations due to lack of clinical evidence	45–65% of total daily calories (minimum intake: 130 g/day)	55–60% of total daily calories	Try to reduce current carbohydrate intake by 10–15%
Fiber/glycemic index	High-fiber and low-glycemic index diet	High-fiber diet: increased intake of soluble and insoluble fibers	Intake of fiber-rich foods	Concordant with all current recommendations
Preferred sources	Fruits, vegetables, whole grains, legumes and dairy products (milk and yoghurt)	Pulses, legumes, coarse grains, sprouted grams, unprocessed vegetables and fruits Substitution of polished white rice with millets and brown rice	Cereals, mixed coarse grains, whole grains (eg, ragi, oats, barley, jowar), whole pulses, whole fruits, salads and soybeans, leafy vegetables, fenugreek seeds Restricted intake of all-purpose flour (maida)-based products	Concordant with all the current recommendations
Proteins
Recommended intake	Typically 15–20% of total energy in individuals without diabetic kidney disease Recommended daily allowance in individuals with T2DM and compromised renal function: of 0.8 g/kg body weight/day	10–15% of total daily calories	10–15% of total daily calories	Try to increase the current protein intake by 10% to a maximum of 1 gram/kg body weight/day
Preferred source	Preferred sources: not mentioned	Preferred sources: not mentioned	Vegetable sources, low-fat milk and milk products, fish and lean meat	Concordant with ICMR guidelines
Fats
Recommended intake	No specified ideal intake	No specified ideal intake	20–25% total daily calories	Try to minimize visible fat intake
Other restrictions	Restricted intake of saturated fats: <10% total daily calories Minimal intake of trans fats Restricted intake of dietary cholesterol: <300 mg/day	Restricted intake of saturated fats: <10% total daily calories Minimal intake of trans fats Restricted intake of dietary cholesterol: <300 mg/day	Restricted intake of saturated fats: <7% total daily calories Minimal intake of trans fats ((hydrogenated vegetable fats) Restricted intake of dietary cholesterol: <300 mg/day	Concordant with all current recommendations
Preferred source of MUFA/PUFA	Fatty fish, nuts and seeds	Moderate intake of fish/seafood, chicken without skin and red meat^a as a source of PUFA Not recommended: sunflower oil	Groundnut, sesame, cotton seed, rice bran or safflower along with soybean, mustard, canola etc as preferred choices for edible oils containing MUFA and PUFA	Concordant with all current recommendations
Sugars and sweeteners	Reduced intake of HFCS and sucrose Substitute nutritive sweeteners with non-nutritive sweetener Natural fructose/free fructose from fruits (3–4% of energy intake and not >12) is permissible	Reduced intake of refined sugars Moderate intake of non-nutritive artificial sweeteners Avoid consumption of HFCS	Avoidance of sugar, honey, jaggery Restricted use of artificial sweeteners and avoidance in pregnant/lactating women with diabetes Avoidance of very sweet fruits and fruit juices	Concordant with all current recommendations
Micronutrients and other dietary recommendations
Micronutrients	No specific recommendations made	Inclusion of micronutrients (chromium, alpha-lipoic acid, magnesium and zinc) as adjunct to standard care^b	No specific recommendations made	Ensure adequate micronutrient intake through diet and exogenous sources
Salt	Restricted sodium intake: <2300 mg/day^c	Restricted intake of dietary salt: <5 g/day^c	Restricted intake of dietary salt: ≤6 g/day	Concordant with all the current recommendations. Also restrict non-salt sources of sodium (eg ajinomoto)
Alcohol/tobacco	Alcohol allowed in moderation	Avoid alcohol; cessation of tobacco use	Moderate alcohol consumption; cessation of any form of tobacco use	Concordant with ICMR guidelines

Notes: ^aParticularly in patients with established cardiovascular disease; ^binsufficient evidence available; ^cfurther restriction in patients with diabetes and hypertension. Data from these studies.^15,53,61

Abbreviations: ADA, American Diabetes Association; HFCS, high-fructose corn syrup; ICMR, Indian Council of Medical Research; MUFA, mono-unsaturated fatty acids; PUFA, poly-unsaturated fatty acids; RSSDI, Research Society for the Study of Diabetes in India; T2DM, type 2 diabetes mellitus.

Figure 6 Plate method for meal planning.

Figure 7 The culinary pentad/“Degustation Pentad”.

Notes: Data from these studies.^54,64

Figure 8 The seven A of MNT.

Notes: Data from these studies.^53,54

Table 11 What to Assess and Monitor in Patients with Diabesity

Parameter	Assess	Monitor
Food- and nutrition-related history	Beliefs and attitudes, including food preferences and motivation Food environment, including access to fruits and vegetables Dietary behaviors, including eating out and screen time Diet experience, including food allergies and dieting history Medications and supplements Physical activity	Beliefs and attitudes, including motivation Food environment, including access to fruits and vegetables Dietary behaviors, including eating out and screen time Medications and supplements Physical activity
Anthropometric measurements	Height, weight, body mass index Waist circumference Weight history Body composition	Weight, body mass index Waist circumference Weight history Body composition
Biochemical data, medical tests, and procedures	Glucose and endocrine profile Lipid profile	Glucose and endocrine profile Lipid profile
Nutrition-focused physical findings	Ability to communicate Affect Appetite Blood pressure Body language Heart rate	Affect Appetite Blood pressure Body language Heart rate

Table 12 ABCDE Approach to Counselling in Diabesity

Counselling Methodology

A: Ask permission to assess

B: Be systematic

C: Communicate with empathy

D: De-stress the patient

E: Engage all stakeholders

Counselling Content

A: Agree upon goals/targets

B: Behavior change

C: Cycling of weight (prevention)

D: Diet and nutrition therapy

E: Exercise

Figure 9 Diet is the main factor affecting composition of gut microbiota.

Figure 10 Different aspects of personalized nutrition.

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