Stick to the plan

Dr Sam Robson charts a patient’s journey on her clinic’s weight-loss programme through lockdown

CONSULTATION

Giulia is 43 and came to the clinic in early 2020. Prior to coming for consultation she was sent all the consultation paperwork to complete; this includes details of her medical, family, social and dieting history. She is an Italian teacher who doesn’t smoke, likes wine and has school-age children. She had previously tried weight-loss programme Alevere, which had been effective in helping her lose weight, but once she had lost the weight and returned to her previous habits, the weight predictably came back on. She had also tried simply restricting her food intake and exercising but found nothing worked because she couldn’t stick to it.

Giulia was a member of a gym but did not prioritise going or making this part of her routine. She was sporadic in her gym efforts and it was important to explain that physical activity is crucial to maintaining weight loss, but it is the diet that actually takes the weight off. She was aware that she needed to make a commitment to a programme that she thought could work. Discussion about her previous efforts really emphasised the need to do something different in order to maintain the weight loss. She is Italian and loves Italian food; and had not yet found a maintenance plan that accommodated her tastes, culture and dietary needs.

We agreed on a target weight of 65kg and a target body fat percentage of 25-30% (she started at 37.2%). Body fat percentage is a much more reliable and valid indicator than weight since it is really body composition that should be changed. BMI is not a good measure for individuals because it is just a calculation based on height and weight and does not look at age, gender, muscular build or ethnicity. We have an InBody body-composition analyser that allows us to measure body fat, visceral fat, metabolic rate, muscle mass and weight, and is essential for tracking progress and establishing goals. The goals for our patients are to have a healthy percentage body fat, a healthy visceral fat and a good muscle profile – both for aesthetics and to boost the metabolic rate.

Temple Vie patients undergo a psychological screening which in this case clarified that Giulia eats when she is bored and also can eat when emotionally upset. This highlighted the need to have some easy strategies in place so that she has alternative options in these scenarios. Part of the psychological support involves rehearsing and imagining situations where food might have been the automatic response – it’s not easy to change a habit but being aware of it and then practising doing something different can be an effective way of addressing it. I point out to anyone with high emotional eating scores that if these habits and behaviours are not adjusted then they will always be there to trip them up when the discipline of the diet dies down. Giulia wanted to lose 10kg and hoped to do so before she planned to go to Italy in April 2020.

PLAN

“I point out to anyone with high emotional eating scores that if these habits and behaviours are not adjusted then they will always be there to trip them up when the discipline of the diet dies down”

We agreed that a blast on the Temple Vie programme would be Giulia’s best option, explaining that it was different from Alevere and that after losing weight she would be followed up actively for two years on the maintenance plan. Giulia started the programme at the start of March 2020 and at that point there was a possibility that covid-19 (as we now know it) might interrupt her holiday plans, but we had no concept at that point how it might disrupt her dieting.

Giulia has MS but this is well controlled, so the first stage of the programme – weight loss – was pretty standard for her, and it was anticipated that she would attend weekly for LPG Endermologie body-contouring treatments (which stimulates lymphatic drainage, breaks down stubborn fat and works to smooth and tighten skin), and monthly for medical reviews. She was encouraged to continue with her exercise routine but advised that we would be focusing on this much more when she had reached her target weight. It is hard to effectively build muscle when you are on a very low carb diet (during the weight loss stage patients eat five to eight high-protein, lowcalorie sachets per day) and also many people feel more comfortable going to the gym when they have lost some weight.

The weekly body-contouring appointments are about more than just having a treatment; the appointment also provides an opportunity to monitor, motivate and counsel the patient, discussing any particular challenges (usually social) and making sure Giulia was eating enough of the correct fruit and vegetables and taking her supplements. The fruit and veg on the plan were carefully selected so as to provide taste and crunch but not too many carbs, while the supplements are to counter the effects of being in ketosis. When in ketosis, the biochemistry of the body changes – you urinate a lot more and can get light headed, dizzy and have cramps, so the supplements help to balance this.

It became quite apparent after 23 March that Giulia could not attend for treatments or monthly supervision, so we kept in touch remotely by email and virtual consultation. Of course, there is no virtual alternative to bodycontouring treatments but we could still provide the support and monitoring from a distance.

We organised regular deliveries of the sachets and supplements as required and Giulia was encouraged to do more exercise. Her gym set up online classes during lockdown and I also sent her links to routines and exercise classes. We also provided remote blood testing in order to be sure she was properly medically supervised, and Giulia kept me informed about her weight.

RESULTS

Once a patient has reached their target weight, the focus is on introducing all the normal food groups and developing a good physical activity routine. The InBody is very good for monitoring progress here because in response to exercise you can see where fat has been lost and muscle gained, which may not show well on the scales.

The maintenance stage is for two years and involves regular reviews – initially monthly – looking at body composition, food diaries, exercise habits and discussing any challenges or upcoming social events for which patients need a “plan”. If patients “fall off” this is never an issue. They can feel embarrassed but we are not at all judgemental or disappointed. Weight loss is like giving up smoking or anything else; for some people it takes many attempts to be successful and often it is just about putting enough steps in place and having strategies to keep them on track with regular gym attendance and eating well. 

After three months Giulia had lost over 10kg, dropped two dress sizes and lost nearly 8 inches from her waist. One of the main things that Giulia liked and fed back on about the plan was the amount of support she received. She said she knew we were always there in the background and available by phone, Zoom or email. I sent her blogs and webinars with bitesized bits of information on issues relating to her particular needs and interests, and we will be creating more of these on different topics for future Temple Vie patients.