When weight loss is not self-motivated: Cognitive behavioral and medical nutrition therapy for weight management in a case of idiopathic intracranial hypertension

Idiopathic Intracranial Hypertension (IIH), also known as pseudotumor cerebri, is a rare syndrome of elevated intracranial pressure of unknown cause mainly occurring in obese females of childbearing age [1]. As it can be only diagnosed with exclusion of other disease, a detailed clinical history, imaging and cerebrospinal fluid examination are essential. Symptoms include intracranial pressure, including headaches and papilledema, which can result in progressive irreversible visual loss and optic atrophy. Treatment depends on the disease stage and aims to alleviate symptoms and preserve problems in vision. Additionally, weight management is recommended aiming a weight loss of at least 5-10% in obese patients, along with a low-salt diet.


Introduction
Idiopathic Intracranial Hypertension (IIH), also known as pseudotumor cerebri, is a rare syndrome of elevated intracranial pressure of unknown cause mainly occurring in obese females of childbearing age [1]. As it can be only diagnosed with exclusion of other disease, a detailed clinical history, imaging and cerebrospinal fluid examination are essential. Symptoms include intracranial pressure, including headaches and papilledema, which can result in progressive irreversible visual loss and optic atrophy. Treatment depends on the disease stage and aims to alleviate symptoms and preserve problems in vision. Additionally, weight management is recommended aiming a weight loss of at least 5-10% in obese patients, along with a low-salt diet.
Herein we describe a young obese woman referred one year ago, with the diagnosis of IIT, in order to lose weight. dull vision for the last 1.5 month, mainly focused on the right side. Informed consent was signed for evaluating and publishing data of intervention.
Neurological examination revealed no pathological data at entrance and exit of the hospital. The patient had no history of allergies, the Electrocardiogram shown sinus rhythm, and chest X-ray depicted lung areas in normal condition. Head MRI revealed optic nerve edema in both sides, slightly bigger in the right side, with no alterations in cerebral parenchyma, mid-line structures appeared undamaged, abdominal system and subarachnoid spaces of normal morphology and topography, as well as normal imaging of optic nerve.
Lumbar puncture showed increased pressure of cerebrospinal fluid (30 cm Η2Ο column), with normal cell and biochemical measurements and negative culture for infections and virus. Brain MRV was also performed The patient was started on acetazolamide 250 mg twice a day, during hospitalization, resulting on reduction of symptomatology. After regular ophthalmic assessment the eye edema reduced. The patient left the hospital 6 days after entrance, with the recommendation to visit the hospital dietitian for further dietary and lifestyle changes.

Dietary intervention
At the first visit all important information regarding clinical, dietary and environmental data of the patient (Table 1) were collected in order to design the medical nutrition therapy (MNT) according to the Nutritional care process (NCPM) [2]. This included nutritional assessment, nutritional diagnosis, nutritional intervention and nutritional monitoring and evaluation. Signed informed consent was obtained by the patient at the beginning of the treatment. Compliance to Mediterranean Diet was assessed (MedDietScore) at the beginning and end of the treatment period [3]. The dietary therapeutic intervention aimed for an approximate of 15-20% weight loss (107-99 kg respectively) over the next 1 year, based on appropriate nutritional education ( Table 2).

Cognitive behavioral therapy
Two months after the initiation of the dietary intervention, Cognitive Behavior Therapy (CBT) was introduced in the therapeutic scheme in order to enhance the MNT process. CBT specifically focused on motivation for changing eating habits and physical activity routines. At the initial assessment the patient filled Beck Depression Inventory II (BDI -II) [4] and Beck Anxiety Inventory (BAI) [5] questionnaires scoring 15 and 27 respectively. CBT program was developed according to the Cooper/Fairburn approach to the treatment of obesity [6] organized in a series of treatment modules that included: 1. starting treatment: pre-admission phase; 2. establishing and maintaining weight loss; 3. encouraging acceptance, addressing realistic expectations to body weight, and addressing body image concerns; 4. long-term weight maintenance; 5. Physical activity were implemented throughout the Rare consumption of non refined cereals, legumes and red wine, low consumption of fruit and even lower of vegetables, increased consumption of cheese and red meat, and use of olive oil on a daily base. Increased consumption of white bread in a daily base, products from white flour ie pasta, cereals, Increased consumption of salty products such as olives, whole fat cheese, cold cuts, ready made cheese pies, pizzas and croissants, potato chips, pop corn, packaged fruit juices and soft drinks. Seed oils and mayonnaise part of her diet on a daily base. Eats visible fat from meat and usually cooking is in non-stich cookware.
Does not add salt in her food during meal, but often eats precooked meals or orders fast food. Takes a B12 supplement on a daily base for the last 2 years (without a doctors/dietitians recommendation  program [7]. CBT was performed for 16 consecutive weeks. The psychological intervention focused on treating issues related to the significance of slow but stable rhythm of weight loss for the next 2 years, body image issues, enhance motivation for changes regarding everyday routines related to body weight and physical activity, prioritize changes set by the dietitian, enhance the significance of weight loss for treating symptoms of IIH, with a focus to the impaired vision and headaches.

Outcomes
KM was diagnosed with Class III obesity, due to inadequate nutritional education resulting to consumption of increased energy intake, big food portions and increased intake of food products high in fat, salt and simple dietary sugars as seen from the 24 hour recall and food frequency questionnaire. MedDietScore at start point was 18. The dietary therapeutic intervention aimed for an approximate of 15-20% weight loss (107-99 kg respectively) over the next 1 year, based on appropriate nutritional education ( Table 2). Sessions with the dietitian were repeated every 2 weeks for the first 6 months and once per month for the next 6 months. Nutritional intervention was designed to reduce portion sizes, fat, sugar and salt intake (<2500 mg sodium intake) and overall energy intake, increase consumption of dietary fiber, unsaturated fat and motivate patient to have a healthier lifestyle. Additionally, enhancement of cooking skills was aimed into a model adapted to the Mediterranean diet.
For the first three months the level of compliance was low, and the patient lost only 1 kg instead of the lowest aim for this period set of 5 kg loss. Obstacles derived from parental beliefs, previous unsuccessful effort to lose weight, as well as unmet expectations like faster weight loss and improvement on self-esteem.
The psychological intervention thereafter focused on treating issues related to the significance of slow but stable rhythm of weight loss for the next 2 years, body image issues, enhancement of motivation for changes regarding everyday routines related to body weight and physical activity, prioritization of changes set by the dietitian, enhancement of the significance of weight loss for treating symptoms of IIH, with a focus to the impaired vision and headaches.
Throughout the consultation appropriate behaviors were rewarded, negative beliefs that could generate negative conclusions, anxiety, depression and guilt were explored. The patient was motivated to change her beliefs about general self-efficacy and those related to weight change and control. After the end of the CBT sessions she filled again BDI-II and BAI questionnaires scoring 12 at BDI-II and only 8 at BAI, showing significant improvement on her anxiety level. Afterwards, some motivation interview strategies were included in the medical nutrition therapy [8]. After the fourth month of the initial visit and from the first month of CBT, the patient became more cooperative with the dietitian, and accepted suggestions regarding dietary and activity routines.
At the end of the first year from the initial visit the patient lost 26% of the initial weight (96 kg) and increased her MedDietScore to 38. Additionally, initial symptoms of dull vision and headaches, principal symptoms of IIH, did not reoccur during the period of intervention.

Discussion and conclusion
A case of a young obese woman diagnosed with IIT and the underlying effectiveness of a structured medical nutrition therapy when combined with CBT for obesity is described herein.
CBT is well recognized as effective for the psychological intervention in eating disorders sufferers. It has been previously discussed for treating obese patients in order to loose weight, avoid invasive medical procedures and also minimize subsequent weight regain [7].
Motivational interview has also been previously discussed for adding effectiveness to the weight loss trip [9], but still research is needed in the area, as previous mode of application appears with methodological insufficiencies [10]. Nevertheless, in our case we found that CBT was of favor for the initial intervention, as the patient suffered from significant distortions from past experiences and beliefs for own-self regarding among others body image and diet management. Motivational interviewing as a secondary intervention can add value to both the MNT and CBT.
Medical nutrition therapy of obese people is important to educate patients into healthier dietary models and lifestyle behaviors. This way weight loss is promoted and weight regain obstructed. Cognitive behavioral therapy should be in parallel part of the intervention program, in order to enhance self esteem and capability of the patient to recognize previous experiences or habits, related to dietary habits and body image, that may inhibit or cause problems into sustaining weight loss [11]. Cognitive behavioral therapy (CBT) is traditionally recognized as the best established treatment for binge eating disorder and the most preferred intervention for obesity, and could be considered as the firstline treatment among psychological approaches, especially in a longterm perspective; however, it does not necessarily produce a successful weight loss [12]. For the long term and follow up period, motivational interviewing can add effectiveness to weight loss [8,13,14].
To sum up with, herein we describe a case of a young adult woman suffering from IIH, due to obesity stage III, who benefit from the combination of MNT and CBT. Limited knowledge of healthy eating, previous unsuccessful weight loss experiences and low selfesteem build tough barriers for successful weight loss. Weight and stress related to weight management, body image and self-esteem were significantly reduced. Severe anxiety level reduced after the CBT intervention, resulting on significant effort of the patient to change eating and physical activity habits. This is a typical example of patients referring to a dietitian, after a doctor's recommendation for weight loss, due to the serious health complications of increased body weight. As these patients need additional motivation and education to adapt into a new healthier model of life, intense MNT and CBT appear more than promising into dissolving distortions and achieving long term dietary and physical activity changes.