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Very Low Calorie Diets (VLCDs) in Clinical Practice

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1 Very Low Calorie Diets (VLCDs) in Clinical Practice
How to Use the VLCD with Supplements 61st Annual Obesity & Associated Conditions Symposium; American Society of Bariatric Physicians; Las Vegas, Nevada; November, 2011 How to Use the VLCD with Supplements - Discover how to safely use the Very Low Calorie Diet when treating obesity and chronic diseases. Learn about the efficacy of meal replacements and different protocols. Recognize lifestyle modification and behavioral change as the cornerstone of obesity management

2 Joan Temmerman, MD, MS, FAAFP, CNS
Medical Bariatrician, IU Health Bariatric & Medical Weight Loss Assistant Professor of Clinical Medicine, Dept. of Medicine, IU School of Medicine Assistant Professor of Clinical Family Medicine, IU School of Medicine Board of Directors, American Board of Obesity Medicine Diplomate, American Board of Bariatric Medicine Diplomate, American Board of Family Medicine Fellow, American Academy of Family Physicians Certified Nutrition Specialist

3 Begin with discussing nutritional ketosis; 1st review overall actions of insulin. Insulin prevents lipolysis and ketogenesis. Dietary CHO drives insulin production, so restriction of carbohydrate (CHO) leads to lipolysis and the formation of ketone bodies by the liver. Together, these lead to reductions in hepatic glucose output via inhibition of gluconeogenesis and reduced glycogenolysis

4 Nutritional ketosis: role of CHO & insulin
Dietary CHO primary insulin secretagogue Insulin inhibits adipocyte lipolysis CHO restriction lowers endogenous insulin production, allowing lipolysis Metabolism directed from fat storage to fat mobilization & oxidation CHO intake drives insulin production; A powerful way to lower insulin levels is to reduce dietary CHO; then metabolism shifts to fat catabolism. Diuresis; natriuresis; kaliuresis; rapid lowering of plasma glucose; Preservation of lean body mass; Ketones suppress appetite. A protein-rich meal leads to release of both insulin and glucagon.  The latter stimulates gluconeogenesis and release of the newly formed glucose from the liver to the blood stream.  The very moderate rise in insulin associated with the protein meal stimulates uptake of the sugar formed in the liver by muscle and fat tissue.  

5 Insulin inhibits lipolysis in adipocytes turns off lipolysis
turns off lipolysis & ketogenesis Insulin action in adipocytes and ketogenesis in liver. glucagon and adrenalin "turn on" lipolysis while insulin "turns off" breakdown of triglycerides in fat cells.  CHO intake drives insulin production; restrict dietary CHO, lower insulin levels, turn on lipolysis/fat catabolism.

6 Nutritional ketosis: CHO restriction
Ketones produced in liver from oxidation of fatty acids When dietary CHO < 50 gm/day ketones secreted in urine Mild ketosis (no reduction in pH or metabolic acidosis) Fatty acids & ketones major energy sources A powerful way to lower insulin levels is to reduce dietary CHO; then metabolism shifts to fat catabolism. Diuresis; natriuresis, kaliuresis; rapid lowering of plasma glucose; Preservation of lean body mass; Ketones suppress appetite. literature inconsistent on the level of carbohydrate restriction required to allow ketogenesis (<50 g of carbohydrate up to 192 g/day). Ketosis appears to be more dependent on the total carbohydrate intake rather than the degree of calorie restriction (I also use ketogenic LCDs with excellent results; get better wt loss than isocaloric balanced diets and expected loss looking at TEE). After 7-8 weeks, ketones may no longer be secreted. Quantities of other macronutrients may influence this, as up to 57 g of glucose can be produced from 100 g of dietary protein (Baker et al) Β-hydroxybutyrate and acetoacetate. lipid catabolism: β-oxidation and TG clearance.  

7 effects of VLCDs on glycaemia: Calorie restriction leads to glycogen depletion in muscle and liver. Restriction of carbohydrate (CHO) leads to lipolysis (TG broken down to FAs and glycerol) and the formation of ketone bodies by the liver [18]. Together, these lead to reductions in hepatic glucose output via inhibition of gluconeogenesis and reduced glycogenolysis. Unlike starvation, serum glucose levels maintained (gluconeogenesis/protein-burning in liver & kidney from amino acids) and breakdown of muscle mass minimized. Hepatic gluconeogenesis still produces glucose, but ketones suppress hepatic glucose output.

8 Nutritional ketosis Shift to fat catabolism
Diuresis; natriuresis; kaliuresis Rapid lowering of plasma glucose Improved insulin sensitivity Preservation of lean body mass Ketones suppress appetite Unlike starvation, serum glucose levels maintained (gluconeogenesis/protein-burning in liver & kidney from amino acids) and breakdown of muscle mass minimized. Hepatic gluconeogenesis still produces glucose, but ketones suppress hepatic glucose output. Weight loss & decreased fat depots in the liver, muscle and peri-visceral space lead to reductions in insulin resistance. Improved insulin sensitivity, dynamic insulin secretion and reduced hepatic glucose output lead to reductions in blood glucose levels. Glucose falls within days; reaches nadir in 1-2 wks. High protein stimulates insulin secretion and increases satiety. Circulating ketone bodies probably contribute to tolerability of the diet by suppressing appetite in the hypothalamus.

9 Meal replacements (MRs) Why are they so effective?
Improved nutrition Portion control Portion control and MR very powerful interventions Calorie control

10 We live in an obesogenic society
Obesity not just an issue of personal responsibility 2/3 of Americans are overweight or obese Obesity is community and population issue Difficult to make good decisions in environment where healthy options are not available With 2/3 of Americans overweight or obese, we cannot blame it solely on personal responsibility (although food & beverage industry focus only on this). Not character flaw, weakness, self-control issue; Public perception … obesity is a disorder of willpower. Blaming the victim is counterproductive; because many factors contribute to obesity, the solution must also be multifactorial and involve both societal and environmental changes. Prevention of obesity will require policy and environmental changes that will affect large populations; society as a whole will need to regulate the food environment (population-level issue) we tell people to eat less and exercise more, but the obesogenic environment promotes the opposite! (encourages consumption of large quantities of food, high in calories, sugar, fat) Eating well and being physically active takes more than just willpower. We need programs and policies that make healthy food and a healthy llfestyle more available, that disclose the calorie content of restaurant foods, and that teach people how to make healthy eating easier.

11 Not just fast food: Portion sizes, sub optimal nutrition (high in calories and fat), unavailable nutritional information. Cheap, tasty food with empty nutrition. healthy food does cost more. very large nos of people consume energy dense food of poor nutritional value Toxic environment

12 Cars are the new dining room!
Eating on the run. Car Swivel Saucer. With it you can finish your lunch in your car. “Whether you’re eating on the run or holding necessities, this swivel tray puts what you need at your fingertips. It attaches to a standard cup holder–the jointed arm swivels from driver to passenger and may be raised or lowered to your liking. It has a textured center to keep items from rolling or sliding. 360-degree swivel design locks in place. Car Swivel Saucer

13 Eating out is associated with obesity
50% of US food expenditure is now spent on food outside the home Increased eating out coincides with increasing overweight & obesity in the US very large nos of people consume energy dense food of poor nutritional value. American households spend ~50% of their total food budget on foods prepared outside of the home, up from 25 percent in Because this marked increase occurred as obesity rates were rising, eating out leads to excess caloric intake and poor diet quality Todd JE, Mancino L. Amber Waves June USDA ERS Neil K. Mehta, MSc and Virginia W. Chang, MD, PhD. Weight Status and Restaurant Availability: A Multilevel Analysis. Am J Prev Med February ; 34(2): 127– Accessed May 10, 2011

14 Sources: Flegal et al.& Ogden et al; USDA Food Expenditure Tables.
Eating out is associated with obesity; trend of shifting from eating at home to eating out coincides with the increasing prevalence of overweight & obesity in the US (McIntosh). Neil K. Mehta, MSc and Virginia W. Chang, MD, PhD. Weight Status and Restaurant Availability: A Multilevel Analysis. Am J Prev Med February ; 34(2): 127–133. Sources: Obesity estimates obtained from Flegal et al. and Ogden et al. Food expenditure data are from U.S. Department of Agriculture Food Expenditure tables Trends in restaurant expenditures and obesity in the United States, 1940–2004. Sources: Flegal et al.& Ogden et al; USDA Food Expenditure Tables. Neil et al, Am J Prev Med February ; 34(2): 127–133

15 Eating Out Increases Daily Calorie Intake
Food away from home has a significant impact on caloric intake and diet quality Poorer diet quality (more calories, fats and carbohydrates) & larger portion sizes compared to foods at home People select more indulgent food when they eat out: more calories, fat, and saturated fat than at-home meals and snacks Glanz et al, 2007; Mancino et al, 2009 Todd & Mancino 2010; Neil et al; 2008 Not only where one eats but what one chooses. People choose less healthful foods when eating away from home (Mancino et al) Eating Out Increases Daily Calorie Intake - Amber Waves December Todd & Mancino USDA ERS ; Neil et al; 2008 Because this marked increase occurred as obesity rates were rising, researchers and policymakers speculate that eating out leads to excess caloric intake ... Neil et al; Am J Prev Med Feb; 34(2):127–133

16 Obesity risk not affected by the type of restaurant
Consumers looking for healthful foods 19% more likely to patronize full-service restaurants than FF (may believe these provide healthier foods) Food at full-service restaurants not superior higher in fat, cholesterol, sodium Although people perceive chain restaurants as healthier, in reality they are not: massive portions served on platters; unavailable or inaccurate nutritional information, very poor nutrition Stewart et al. USDA ERS; Economic Information Bulletin #19,Oct. 2006

17 Calorie Confusion Only 9% of Americans can accurately estimate the number of calories they should consume in a day Half of Americans are unable to estimate how many calories they burn in a day Most Americans don’t track calories consumed or burned citing numerous barriers, including extreme difficulty & lack of interest, knowledge, and focus i.e. energy balance International Food Information Council. There is a large void in dietary and nutritional knowledge, especially calorie confusion. Only nine percent of Americans can accurately estimate the number of calories they should consume in a day for a person of their age, height, weight, and physical activity. Additionally, almost half of Americans are unable to provide an estimate of how many calories they burn in a day (60 percent offer inaccurate estimates). Furthermore, the majority of Americans do not keep track of calories consumed or burned, citing numerous barriers, including extreme difficulty and a lack of interest, knowledge, and focus. IFIC Foundation Releases 2011 Food & Health Survey: Price Approaches Taste as Top Influencer for Americans When Purchasing Foods & Beverages. IFIC Foundation Releases 2011 Food & Health Survey

18 The American Lifestyle
½ of US food budget is spent eating outside the home Clauson & Leibtag, USDA 2011 Only 9% keep track of calories and can accurately estimate how many calories they should eat Physical activity has disappeared 40% of adults get no activity at all Clauson A, Leibtag E. Food CPI and Expenditures Briefing Room. Table 12. US Department of Agriculture. Accessed May 10, 2011 Obese patients underestimate their caloric intake by 40-50% (Lichtman SW, Pisarska K, et al. N Engl J Med 1992;327: )

19 Energy balance Weight management requires knowing calorie (energy) requirements and balance Almost impossible when eating out regularly Only 9% of people in the US can accurately estimate how many calories they should eat. To manage weight, must know how many calories you are taking in; very difficult to do this when eating out. Poor nutrition and massive portions very problematic Obese patients underestimate their caloric intake by 40-50% Lichtman SW, Pisarska K, et al. N Engl J Med 1992;327:

20 Appetizer: 900 calories! Dinner: 1,440 Calories! 1,640 Calories!
9 Onion Rings 900 calories! Dinner: Chicken Finger Dinner Cheeseburger And Fries 1,440 Calories! 1,640 Calories! Source: Nutrition Action Healthletter, October 1996

21 Bloomin’ Onion: 2,210 calories, 160 g fat
Prepared in egg wash & deep fried. A single blooming onion with dressing contains ~ 2,210 calories and 160 grams of fat (48 g sat) mg of sodium. Cheese Fries instead? These will set you back 2,200 calories, 157 grams of fat, and 57 grams of saturated fat (over 3 days worth)! Na 2766 g

22 Dinner + ½ Cheese Fries ½ Blooming onion 1,100 calories, 80 g fat
Outback Special Calories: 1410; fat 77g + Outback Special 12 oz. steak, loaded baked potato, and house salad with ranch dressing: Calories: 1410; Total Fat 77g (sat fat 36g; Sodium mg. “the lighter side” : Chicken Caesar Salad? 907 calories, 60 grams of fat! Add 1-2 glasses wine (100 calories in 5 oz) or 1-2 beers (150 cal each) ½ Cheese Fries 1,100 calories, 79 g fat Chicken Caesar Salad 907 calories, 60 g fat

23 Cheesecake Factory chicken and biscuits: 2500 calories

24 Applebee’s Quesadilla Burger: 1820 calories, 46 grams sat fat

25 More saturated fat than a whole stick of butter!
Cheesecake Factory fried Macaroni and Cheese: calories, 69 grams sat fat four coated cheese-and-white flour balls over creamy marinara sauce supplies 1,570 calories and 1,860 milligrams of sodium, 69 grams of saturated fat—3½ days’ worth—You’d be better off eating an entire stick of butter (57 grams of sat fat and a mere 800 calories) 800 calories, 57 g sat fat More saturated fat than a whole stick of butter!

26 Cold Stone Creamery Lotta Caramel Latte
1,800 calories 90 g fat; 57 g saturated (~ 57 strips bacon) 175 g sugar: 44 tsps ~ 1 cup sugar 1 cup= 48 teaspoons; there are approximately 40 grams of refined sugar in a 12 oz soft drink, which equals about 10 teaspoons of sugar. Colas generally have 9-10 teaspoons of sugar, while orange sodas are an even sweeter choice with closer to 13 teaspoons per 12 oz.

27 2,000 Calories!!!

28 Inactive lifestyle, poor nutrition, calorie imbalance obesity
Physical Activity has Disappeared from the American Lifestyle One third of adults get no PA at all. Inactive lifestyle with poor eating habits and poor nutrition creates the perfect storm for obesity. Mother Nature” has engineered humans to be quite efficient from an energy standpoint. Our ancestors had to survive in very difficult environments, in which energy from food was sometimes limited yet the energy requirements of daily life were rather high. While technology has made life quite comfortable, our level of energy expenditure has dropped significantly. Moreover, an increasing number of people consume energy dense food of poor nutritional value. For these simple and rather obvious reasons, an obesity epidemic is sweeping the world

29 The bigger the portion, the more one eats!
Studies have shown that the bigger the portion, the more people eat; studies on eating behaviors suggest that we are easily miscued about food and quantities of food consumed. Surprisingly, even when an experiment has demonstrated that a patient has been miscued, the patient will deny that these factors have influenced them. We really do think we are in control of our eating behavior even when we are not. Portion control is one of the main factors in successful weight management The bigger the portion, the more one eats!

30 Bottomless bowl Self-refilling bowl Consumed 73% more
Did not believe that they ate more Did not feel more full Wansick et al (2005) People kept eating; ate 73% more until stopping–yet, they didn’t think they ate more. Visual cues affect appetite. Studies on eating behaviors suggest that we are easily miscued about food and quantities of food consumed. Surprisingly, even when a patient has been miscued, the patient will deny that these factors have influenced them. We really do think we are in control of our eating behavior even when we are not Wansink, Brian, James E. Painter, and Jill North (2005), “Bottomless Bowls: Why Visual Cues of Portion Size M

31 Portion control is a main factor in successful weight loss
“The use of portion-controlled servings, including meal replacements, currently has the strongest evidence of long-term efficacy.” Meal replacements promote significantly greater and sustainable weight loss in numerous studies Li Z, Bowerman S, Heber D. Obes Manag 2006;2(1): 23-28 Wadden TA, Butryn ML, Byrne KJ. Obes Res 2004;12:151S-161S. Portion control is one of the biggest factors in successful weight loss. cutting down on portion sizes is highly effective way to combat obesity MR are an easy way to accomplish this. Reduce eating out; remove from toxic food environment. Control environment and focus on lifestyle changes Li Z, Bowerman S, Heber D. Meal replacement: a valuable tool for weight management. Obes Manag 2006;2(1): Wadden TA, Butryn ML, Byrne KJ. Efficacy of lifestyle modification for long-term weight control. Obes Res 2004;12:151S-161S.

32 Meal Replacements (MRs) increase weight loss
“Meal replacements are considered state-of-the-art dietary treatment for overweight and obesity. They produce double the weight loss of traditional plans and they improve long-term maintenance.” Tucker M. Obesity, Family Practice News 12/1/08 Li Z, Hong K, et al. Eur J Clin Nutr 2005;59: MR centerpiece of management for most successful patients; one of the most cost-effective tools; numerous studies show significantly more weight is lost and maintained using portion-controlled, calorie-restricted meals compared to traditional diets. MR produce significantly greater weight loss and weight-loss maintenance. MRs improve dietary compliance, improve nutritional intake Tucker ME. Meal replacements double weight loss, support maintenance. Obesity; Family Practice News; December 1, 2008.

33 DM, Lifestyle intervention & MRs
Look AHEAD Trial: weight loss at 1 year directly related to # of MR; addition of MR to lifestyle group increased weight loss to 8.6% MR are viable and cost-effective for weight loss and maintenance in T2DM Wadden, West, et al. Obesity 2009;17(4): Look AHEAD (Action for Health in Diabetes) specifically looks at success factors for weight loss, of which one factor is commercial MR. Look AHEAD one of the largest diabetes weight management studies that used MR strategy for weight reduction; study aim is to follow health outcomes and mortality among diabetic patients who lose and maintain weight loss for up to 10 years. TLook AHEAD (Action For Health in Diabetes) is a multicenter randomized clinical trial to examine the effects of a lifestyle intervention designed to achieve and maintain weight loss over the long term through decreased caloric intake and exercise. Look AHEAD is focusing on obesity, type 2 diabetes, and cardiovascular disease. The Look AHEAD trial has completed enrollment of 5,145 obese patients with type 2 diabetes. At study entry, participants were randomly assigned to one of two interventions, the Lifestyle Intervention or Diabetes Support and Education. They will be followed for a total period of up to 11.5 years. MR also facilitate maintenance of weight loss, Hamdy O, Zwiefelhofer D. Weight management using a meal replacement strategy in type 2 diabetes. Curr Diab Rep. 2010;10: MR central tool; very effective for maint. And long-term weight control as well. Research-based; over a million patients; documented outcomes. Control portions and calories; provide structure, eliminate decision-making and guessing; improve nutrition. 2 long-term studies on the prevention of diabetes and its complications, funded by the NIH. DPP called attention to efficacy of lifestyle change for improving health Stimulus control: remove from toxic food environment. MR is any prepackaged food product that is portion controlled, calorie controlled, and high nutrition; Typically <300 cal, g protein, g CHO, < 9 g fat. Portion control is one of the biggest factors in successful weight loss. Fabricatore A. The role of structured meal plans and meal replacements in weight management. Medscape Diabetes and Endocrinology; Weight Management Expert Column 3/19/2004. Accessed 1/10/2011 from Bray GA. Let’s treat obesity seriously. Am Fam Physician 2010;81: Hamdy O, Zwiefelhofer D. Curr Diab Rep. 2010;10:

34 “Overweight patients should be encouraged to use MR/portion-
MR diet more effective in reducing metabolic risk factors, insulin & leptin than fat-restricted low-calorie diet Konig D, et al. Ann Nutr Metab 2008;52:74-78 “Overweight patients should be encouraged to use MR/portion- controlled diets” Meal replacement diet more effective in reducing metabolic risk factors, insulin and leptin and improving anthropometric measures than LCD (Konig). Research-based; over a million patients; documented outcomes. Control portions and calories; provide structure, eliminate decision-making and guessing; improve nutrition. Bray GA. Let’s treat obesity seriously. Am Fam Physician 2010;81: Bray GA. Let’s treat obesity seriously. Am Fam Physician 2010;81: Bray G. Am Fam Physician 2010;81:

35 MR: prepackaged food product that is portion controlled, calorie controlled, & high nutrition
<300 cal, g protein, g CHO, < 9 g fat

36 Meal replacements provide:
1. portion control 2. calorie control 3. Structured eating 4. Good nutrition 5. Stimulus narrowing: appetite and intake decrease when there is less dietary variety (fewer flavors, textures, aromas) 6. Stimulus control: remove from toxic food environment sensory specific satiety. stimulus control: remove from toxic food environment. Control environment and focus on lifestyle changes; control portions and calories, provide structure, eliminate decision-making and guessing, displace poor nutrition with improved nutrition. Stimulus narrowing: appetite and intake decrease when there is less dietary variety (fewer flavors, textures, aromas); MR proven to be the most successful strategy for losing and maintaining wt loss. Simplify food choices, require little preparation, avoid problem foods. Studies on eating behaviors suggest that we are easily miscued about food and quantities of food consumed. Surprisingly, even when a patient has been miscued, the patient will deny that these factors have influenced them. We really do think we are in control of our eating behavior even when we are not. MR is any prepackaged food product that is portion controlled, calorie controlled, and high nutrition: typically <300 cal, g protein, g CHO, < 9 g fat

37 Meal replacements (MRs)
Convenient; cost-effective Healthy alternative to skipping meals Provides structure to eating plan; reduces anxiety over making food choices Compliance improved Convenient: reduces need for additional food shopping and preparation; easy to carry and store; improved nutrition. Cost effective: average American spends ~ $96 to $101/wk on food; women $87-105; men $93-109); weekly food costs for MR program ~$41 mVLCD. Psychology/behavioral: stress and pressure of choosing foods, planning, shopping relieved; creates structure; remove from toxic food environment. Control environment and focus on lifestyle changes; control portions and calories, provide structure, eliminate decision-making and guessing, displace poor nutrition with improved nutrition. MR proven to be the most successful strategy for losing and maintaining wt loss. Simplify food choices, require little preparation, avoid problem foods. Studies on eating behaviors suggest that we are easily miscued about food and quantities of food consumed. Surprisingly, even when a patient has been miscued, the patient will deny that these factors have influenced them. We really do think we are in control of our eating behavior even when we are not.

38 MRs displace calories & poor nutrition
Example: Typical Meal Meal Replacement Approx. Savings Sausage biscuit 510 calories Shake: 100 cals. 400 cals. Breakfast Dinner: 1550 cals. Shake + bar or lean meal 260 cals. Dinner 1300 cals. Portions controlled; calories saved; good nutrition replaces poor nutrition. Walking burns about 100 calories/mile (moderate 3 miles/hr; brisk 3.5) Using two meal replacements saves 1700 cal. 1700 cal ≈ walking 17 miles (about 5 hours)

39 Meal replacements in VLCDs
MR products commonly used (total or partial food replacement) Nutritionally complete commercial products (vitamins, minerals, trace elements, fiber) Different products available (Robard, MediFast, Optifast); nutritional contents vary Nutritionally complete although products/contents vary (Na, K, Mg, Ca); Protein is the emphasized macronutrient; Positive nitrogen balance and preservation of LBM; usually whey or soy protein. As energy intake decreases, protein requirement increases

40 Definition of Very Low Calorie Diets (VLCDs)
kcal/day; ~800 calories favored ~ g high quality protein CHO restricted; nutritional ketosis VLCD and Protein Sparing Modified Fast (PSMF) used interchangeably Low Calorie Diets (LCDs) > 800 kcal; typically kcal/day 1. Ketogenic (CHO restriction) 2. balanced VLCDs most extensively used weight loss intervention in scientific literature.; one of most effective interventions for significant fat loss. No advantage to reducing calories/energy below 800 cal. PSMF & VLCD used interchangeably (PSMF uses regular food: lean meat, fish, fowl, vegetables, MV); VLCD liquid meal replacements. As energy intake decreases, protein requirement increases My clinical practice: I use ketogenic diets for those who aren’t appropriate for VLCD; still get good results. Have to look at RMR and body composition; many obese women with RMR ; won’t lose weight on 1200 cal; use RMR and customize nutritional approaches. Any diet plan can be ketogenic if CHO restricted (typically <50 g), but VLCD is both calorie and CHO restricted

41 History of VLCDs Present since 1929
Reintroduced 1970s (Blackburn) protein-sparing modified fast (PSMF) Last Chance Diet (liquid protein): late 70’s low-quality protein (hydrolyzed collagen) No vitamin/mineral supplementation No medical supervision 60 deaths (cardiac) VLCDs have been around for more than 6 decades in various forms, even complete starvation. Modern VLCD developed in 1960’s: as effective as starvation but without side effects and large loss of lean body mass; 1973 Blackburn used meat & egg albumin to spare loss of body protein (PSMF); + nitrogen balance. Liquid protein diet (Last Chance diet) was modeled after PSMF but used low-quality protein from hydrolyzed gelatin & collagen; not supplemented with vitamins & minerals. ~100,000 people used Last Chance Diet as sole source of nutrition for at least 1 month during 1977; 60 deaths: myocardial atrophy and cardiac arrhythmias and electrolyte abnormalities poor-quality protein. Negative nitrogen balance; excessive loss of LBM. VLCDs fell into disfavor.

42 VLCDs today Safe under experienced supervision
Medical monitoring mandatory (MD trained & experienced in use of VLCDs) Protein g/kg IBW (150% of RDA) ~ g daily High-quality protein (whey isolate ,soy) Carbohydrate restricted (ketogenic) Nutritionally complete commercial products (vitamins, minerals, trace elements, fiber) More fat for gallbladder contraction Modern VLCDs extremely safe; no increased cardiac arrhythmias or electrolyte abnormalities. Nutritionally complete (also contain the recommended daily requirements for vitamins, minerals, trace elements, fatty acids and protein). although products/contents vary (Na, K, Mg, Ca); Protein is the emphasized macronutrient; Positive nitrogen balance and preservation of LBM; usually whey or soy protein. As energy intake decreases, protein requirement increases While on the diet, pts must be taught to modify their eating and exercise habits and lifestyle behavior. Behavior modification includes self-monitoring, stimulus control, reinforcement, and cognitive restructuring. Incorporate resistance to preserve LBM and RMR). RDA protein 0.8 g/kg IBW; daily reference value (DRV) 50 g. (Krause p.446, p.345) May need to supplement with Na, K, Mg

43 VLCDs today Rapid weight loss: 3-3.5 # week F; 5 # wk M
Most patients will lose # in wks Heavier patients lose more Typical maximum: ~ 1/3 of TBW; < 25% LBM; >75% fat mass Rapid weight loss boosts motivation and produces better results Multidisciplinary approach: behavior, nutrition, exercise (aerobic and resistance) most aggressive nonsurgical intervention for obesity; simple; produce rapid weight loss; not associated with hunger; pts feel good. VLCD by far most extensively used wt loss method in the scientific literature; used by millions of people. Motivated pts can lose about 1/3 of wt (300# 200#; 400#~130# loss to 270# good result). Need to monitor body composition during weight loss, especially with VLCDs. Minimize loss of LBM (add resistance)

44 VLCDs today Highly structured intervention
Typically commercial MR products used (total or partial food replacement) MRs increase adherence and weight loss Remove from food environment While on the diet, pts must be taught to modify their eating and exercise habits and lifestyle behavior. Control environment and focus on lifestyle changes. reinforcement, and cognitive restructuring. Exercise core component: incorporate resistance to preserve LBM and RMR. Meal replacements (MRs) increase adherence and weight loss

45 VLCDs: patient selection
BMI ≥ 27 with co-morbidities; ≥ 30 without Rapid weight loss Highly motivated Medical co-morbidities stable Contraindications: T1DM, recent MI or CVA, cardiac arrhythmias, unstable angina, unstable illnesses, active cancer, pregnancy/lactation, serious psychiatric diseases, renal or liver disease, substance abuse, extreme ages CI: pregnancy or lactation, malignant cardiac arrhythmias, unstable angina, renal ds (creatinine > 2.5), hepatic failure, unstable psychiatric disorders, T1DM, seizure disorder, current cancer, substance abuse, high-risk occupations (airline pilot), extreme ages. Most bariatricians wait 3 months aftre MI or CVA

46 Medical monitoring Obesity workup:
history, including weight history, PE EKG, CMP, FLP, CBC, TSH, UA, (A1c*) Body composition; measurements Weekly*/biweekly monitoring: BP, HR, weight Lytes q2-4 wks; FLP (A1c) q 3months Body composition EKG every # wt loss All pts closely monitored; but especially close monitoring of pts with DM or HTN (rapid adjustments in diabetic & HTN meds). The workup should follow the guidelines provided in the American Society of Bariatric Physicians (ASBP) Overweight and Obese Evaluation and Management, TSH should be in the 0.4 – 2.0 range for dieting. Use team approach. Can do weekly group visits as well, but need MD involvement (at least monthly). *regular f/u essential; complicated patients wkly

47 Medical monitoring Hold diuretics Hold oral hypoglycemic agents
Stop Bolus insulin; basal insulin stopped if < 30 units daily; reduced 50% if > 30 units/d Anti-hypertensives may need rapid adjustment Monitor medications whose serum levels must be closely followed (coumadin, theophylline , etc) Diuresis; natriuresis; kaliuresis; rapid lowering of plasma glucose; hepatic and renal metabolism of these meds may vary while on VLCD. Remember Li is typically considered CI) . May need to supplement with Na, K, Mg

48 Side effects Minor & transitory: hunger, fatigue, weakness, nausea, lightheadedness, muscle cramps Constipation, cold intolerance, hair loss (telogen effluvium; temporary), dry skin Transient elevation of uric acid (if h/o gout, consider allopurinol 300 mg qhs for prophylaxis) Diuresis; natriuresis; kaliuresis Transient elevation of uric acid levels at onset (early weeks): increasing competition for renal secretion with rising ketones. precipitation of gout unusual. For gout, prophylax during VLVD course. Constipation common with dieting; increase fluids + sugar-free fiber daily; MOM prn (stabilizes K). Muscle cramps: check lytes; if nl add slow-release OTC Magnesium chloride. Transient rise in LFTs (fat mobilization

49 Side effects Muscle cramps Dizziness; orthostasis Constipation
symptom treatment Muscle cramps Dizziness; orthostasis Constipation Halitosis Hair loss Dry skin Slow-Mag (OTC) √ lytes Sodium (bouillon) √ BP Fluids, sugar-free fiber daily, MOM prn Listerine strips, sugar & CHO-free mints/gum Reassurance; biotin EFAs (fish oil); lotion HA, fatigue, hunger fairly common transitional symptoms (first several days before ketosis occurs). Warn patients; manage expectantly. OTC tylenol/advil/aleve, bouillon

50 Gallstones 3-8% with current VLCDs ( ~ 800 cal; ≥10 g fat)
Linear relationship between wt and gallstones Increased risk of gallstones during rapid wt loss 25%–35% in obese patients after VLCD low-fat diet (< 600 kcal/d; 1–3 g fat/d) 3-8% with current VLCDs ( ~ 800 cal; ≥10 g fat) Much higher rate of gallstones in obese patients (linear relationship between wt and gallstones); Weight loss is associated with an increased risk of gallstones: increases bile cholesterol supersaturation, enhances cholesterol crystal nucleation, and decreases gallbladder contractility; incidence of new gallstones is approximately 25%–35% in obese patients who experience rapid weight loss after treatment with a very-low-calorie, low-fat diet (<600 kcal/d; 1–3 g fat/d); up to ~25% with rapid wt loss; products & fat content vary; g fat/d; 3-10 g EFA (Blackburn & Kanders); my personal experience ~ 2 %; I offer prophylaxis. Ursodeoxycholic acid therapy can prevent gallstone formation during rapid weight loss [1,2]. The incidence of new gallstones is approximately 25%–35% in obese patients who experience rapid weight loss after treatment with a very-low-calorie, low-fat diet (<600 kcal/d; 1–3 g fat/d) [2,3] or gastric surgery (1004 patients enrolled in a 16-week, 520 kcal/d weight loss program, ursodeoxycholic acid caused a decrease in gallstone formation from 28% in those receiving placebo to 3% in those receiving 600 mg/d of drug [1]. In 233 patients who had gastric bypass surgery, 600 mg/d of ursodeoxycholic acid decreased the incidence of new gallstones from 32% to 2% (2)); 600 mg/d ursodeoxycholic acid is the optimal does for effective prophylaxis of gallstone formation during rapid weight loss. 1. Shiffman ML, Kaplan GD, Brinkman-Kaplan V, Vickers FF. Prophylaxis against gallstone formation with ursodeoxycholic acid in patients participating in a very-low-calorie diet program. Ann Intern Med 1995;122: Sugerman HJ, Brewer WH, Shiffman ML, et al. A multicenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric-bypass-induced rapid weight loss. Am J Surg 1995;169:91-96. Anderson JA, Hamilton CC, Brinkman-Kaplan V. Benefits and risks of an intensive very-low-calorie-diet program for severe obesity. Am J Gastroenterol. 1992;87(1):6-15. (p.5). Saris WHM. Very-low-calorie diets and sustained weight loss. Obes Res. 2001;9(4):295S-301S. (p.3) Ursodeoxycholic acid (Actigall) 600 mg daily optimum for prophylaxis Shiffman ML, et al. Ann Intern Med 1995;122:

51 Health benefits: immediate & dramatic
Rapidly improved glycemic control & CV risks SBP reduced 8-12%; DBP reduced 9-13% TC decreased 5-25%; LDL decreased > 5-15%; TG reduced % Mood, well-being, energy level, QOL, self-esteem improved Glucose falls within days; reaches nadir in 1-2 weeks. BP also drops dramatically (majority of reduction within 1st 3 weeks). VLCD increases insulin sensitivity and reduces the substrate for gluconeogenesis. Thus VLCD treatment may improve glycaemic control more than calorie restriction alone. Blackburn & Kanders, eds. Obesity: Pathophysiology, Psychology and Treatment; 1994

52 Diabetes In general, diabetic patients may find it harder to lose weight: Medications: insulin, TZDs, sulfonylureas Increased food to avoid hypoglycemia Inflammation; adipokines, insulin resistance Insulin & TZDs promote adipose tissue deposition and fluid retention. Insulin anabolic; inhibits lipolysis in adipose tissue; ketogenesis in liver. Diabetic patients do especially well: they may find it harder to lose weight: Medications: Insulin & TZDs promote adipose tissue deposition and fluid retention. Insulin anabolic; inhibits lipolysis in adipose tissue; ketogenesis in liver

53 VLCDs: profound effect on glycemic control
Rapid lowering of plasma glucose (PG) (within days; nadir 1-2 weeks) from calorie/CHO restriction Further PG improvement with weight loss as visceral (intra-abdominal) adipose tissue reduced Rapid weight loss catalyst for lifestyle change Diabetic patients do especially well: they may find it harder to lose weight: Medications: insulin, TZDs, sulfonyureas ; Increased food intake to avoid hypoglycemia; Inflammation; adipokines, insulin resistance (Insulin & TZDs promote adipose tissue deposition and fluid retention. Insulin anabolic; inhibits lipolysis in adipose tissue; ketogenesis in liver), VLCDs increase insulin sensitivity and reduces the substrate for gluconeogenesis, reducing hepatic glucose output. Thus VLCD treatment may improve glycemic control more than calorie restriction alone. 5-10% weight loss reduces visceral fat ~ 30%

54 Baker et al; Diabetes Res Clin Pract. 2009
Rapid lowering of glucose. Schema for the effects of VLCDs on glycaemia. Calorie restriction leads to glycogen depletion in muscle and liver. Restriction of carbohydrate (CHO) leads to lipolysis and the formation of ketone bodies by the liver [18]. Together, these lead to reductions in hepatic glucose output via inhibition of gluconeogenesis and reduced glycogenolysis [59,61,62]. High protein stimulates insulin secretion [64] and increases satiety [65]. Circulating ketone bodies probably contribute to tolerability of the diet by suppressing appetite in the hypothalamus [20]. Weight loss and diminution of fat depots in the liver, muscle and peri-visceral space lead to reductions in insulin resistance [49,50]. Improved insulin sensitivity, dynamic insulin secretion and reduced hepatic glucose output lead to reductions in blood glucose levels [57,58]. A protein-rich meal leads to release of both insulin and glucagon.  The latter stimulates gluconeogenesis and release of the newly formed glucose from the liver to the blood stream.  The very moderate rise in insulin associated with the protein meal stimulates uptake of the sugar formed in the liver by muscle and fat tissue. Baker et al; Diabetes Res Clin Pract. 2009

55 Obesity significant risk for NAFLD
Portal theory. Obesity ass. with steatosis/NAFLD (60-70% of obese pts; steatohepatitis/NASH ~19%. Class 3 obesity (BMI ≥40), 91% and 29%. Pathogenesis of fatty liver/NAFLP not clear: TG may be overproduced in liver with obesity and increased dietary CHO; inappropriate FA metabolism in hepatocytes; elevated serum FFA; or improper packaging of VLDL. Insulin resistance also implicated: Iisulin-sensitizing meds have shown beneficial effect (Tendler)

56 VLCDs and NAFLD Transient rise in LFTs:
Rapid mobilization of intracellular TG and FA release ? portal inflammation Hepatic steatosis reversed after wt loss Both liver volume and fat reduced within 6 wks NAFLD; enlarged fatty liver increases surgical risk, esp. upper abdominal laparoscopic procedures (especially RYGB and Lap Band); hepatomegaly most common cause for conversion to open procedure. VLCDs used to reduce hepatomegaly.

57 Australian study; 32 subjects (19 M; 13 F)
Australian study; 32 subjects (19 M; 13 F). Single cross-sectional images of the liver performed by computed tomography at baseline and week 12 of a very-low-energy diet. The images, taken from within a series of contiguous 8-mm slices used to calculate total liver volume, illustrate the extent of the change in liver volume with weight loss in a 35-y-old man with an initial liver volume of 3.7 L and a final liver volume of 2.4 L. A 35% reduction in liver size and a weight loss of 18 kg/40 # were observed. Australian study; 32 pre-op subjects. Example of liver CT; baseline liver volume 3.7 L; final liver volume 2.4 L after 12 wks VLCD. 35% reduction in liver size; weight loss of 18 kg Colles, Dixon et al. Am J Clin Nutr 2006;84:304-11

58 Colles, Dixon et al. Am J Clin Nutr 2006;84: as measured by serial magnetic resonance imaging (n = 9). An immediate reduction in liver volume occurred in the first 2 wk (P < 0.001) and between baseline and all other time points (P < for all). The decreases in body weight and VAT showed a more uniform change. Significant decreases in weight (P < 0.001) and VAT (P = 0.001) occurred between baseline and week 12. The statistical analysis was conducted by using ANOVA; Tukey's post hoc analysis was used for normally distributed data and paired-samples t test. Subjects with a greater baseline liver volume lost proportionately more liver size over the course of the 12-wk VLED. At the conclusion of the diet, the average decrease in liver size was 18.7%. Most of the reduction in liver size occurs in the first 2 weeks of VLCD Relative change in liver volume, visceral adipose tissue (VAT) area, and body weight during a 12-wk very-low-energy diet. Colles et al, 2006

59 VLCD 16 weeks in 12 obese T2DM patients
BMI decreased from to 27.5 (p < 0.001) A1c improved from 7.9 to 6.3 (p = 0.006) Diastolic function improved Liver enzymes, total cholesterol, TGs, leptin, and CRP decreased significantly Plasma adiponectin levels increased Significant reduction in fat stores Hammer S, Snel M, et al. JACC. 2008 Adiponectin antiinflammatory. Netherlands study; 7 M; 5 F. The BMI decreased from 35.6 ± 1.2 kg/m2 (baseline, mean SEM) to 27.5 ± 1.3 kg/m2 (after the VLCD, p <0.001) and was associated with an improvement in hemoglobin A1c from 7.9 ± 0.4% (baseline) to 6.3 ± 0.3% (after the VLCD, p = 0.006). Myocardial TG content decreased from 0.88 ± 0.12% to 0.64 ± 0.14%, respectively (p = 0.019), and was associated with improved diastolic function (reflected by the ratio between the early and atrial filling phase) from 1.02 ± 0.08 to 1.18 ± 0.06, respectively (p= ). Conclusions Prolonged caloric restriction in obese T2DM patients decreases BMI and improves glucoregulation associated with decreased myocardial TG content and improved diastolic heart function. Therefore, myocardial TG stores in obese patients with T2DM are flexible and amendable to therapeutic intervention by caloric restriction.

60 Fat stores and VLCDs Transverse slice at L5 showing visceral and subcutaneous fat depots in the same patient, illustrating the effects of 16 weeks of VLCD. BMI decreased from 35.6 to 27.5, p < 0.001 Hammer et al. JACC 2008

61 VLCD protocols using products
Complete (all products) Modified (partial products) Numerous variations are possible Customize your approach for patient preference and optimal success Patients can be on modified indefinitely (most commercial limit complete to 16 weeks). I have found that psychologically patients do better on modified; learn how to deal with food, prepare healthy lean meals; progressing into a balanced maintenance plan easier. I am very creative; if have good nutritional knowledge, can manipulate products and food to really individualize approach.

62 Nutritional parameters
Adequate protein (at least 75 g high quality) Calories ~800 g daily CHO ≤ 50 g daily Fluid: minimum 64 ounces daily Remember no advantage to going <700 calories. Some patients are CHO sensitive or insulin resistant; may need to decrease CHO to achieve ketosis. Most products are fortified; as decrease # of products, may need to supplement (MV, Na, K). Monitor lytes. Complete VLCD: MV and bouillion daily. EFA if not having oily fish regularly (inadequate dietary source). Hydration very important: Fluids oz/d

63 Complete VLCD (all products)
~75-90 g protein, 50 g CHO, ~700 cal/d 5-6 MR bars (15 g protein, 13 g CHO,160 calories) shakes (15 g protein, 7 g CHO,100 calories) 2 bars, 3 shakes 2 bars, 4 shakes (most common) 1 bar, 4 shakes 3 bars, 2 shakes Products vary by manufacturer; also contain the recommended daily requirements for vitamins, minerals, trace elements, fatty acids and protein.

64 Modified VLCD: lean meal
3-4 oz. lean protein 7-9 g protein/oz 25-50 calories/oz 2 non-starchy vegetables (no potatoes, peas, corn, ?carrots) 25 calories/serving 5 g CHO/serving Partial food; partial MRs. I have found that modified VLCDs are a better overall approach; psychologically important to learn to deal with food; more flexible, can have family meal (ripple effect; entire family improves nutrition; fairly often pt tells me spouse also lost 20-30#); incorporate work situations (business lunch or dinners); easier to transition.

65 Modified VLCD: 1 lean meal + 4 MR
2 bars (15 g protein, 13 g CHO,160 calories each) 2 shakes (15 g protein, 7 g CHO,100 calories each) ~85-90 g protein, 50 g CHO, ~700 cal/d 2 protein shakes 30 g protein, 14 CHO, 200 cal + 2 protein bars 30 g protein, 26 CHO, 320 calories + 1 Lean meal 28-32 g protein, 10 CHO Standard plan. Individualized nutritional plan; alot of adjusting is necessary; adept at manipulating nutritional plan; many variations

66 Modified VLCD variations
1 lean meal + 4 MR (3 shakes, 1 bar) 3 protein shakes 45 g protein, 21 CHO, cal + 1 protein bar 15 g protein, 13 CHO, 160 calories + 1 Lean meal 28-32 g protein, 10 g CHO More shakes, less bars. could also use 4-5 shakes, no bars (although patients tend to really like bars; very convenient)

67 Modified VLCD variations
1 lean meal + 3 MR; all bars 3 protein bars 45 g protein, 39 CHO, 480 calories + 1 Lean meal 28-32 g protein, 10 g CHO Over 70 g protein but I prefer ~ 80 g; I add protein snack (low calorie cheese stick, egg, 2 oz lean meat)

68 Modified VLCD variations
2 lean meals + 2 MR: 1 shake & 1 bar or 2 bars or 2 shakes protein shake(s) + protein bar(s) + 2 Lean meals 56-64 g protein, 20 g CHO Takes more effort; more food preparation. The more MR used, the easier on patients

69 Behavior modification & lifestyle changes
VLCDs not effective as solo therapy pts must be taught to modify their eating and exercise habits and lifestyle behavior Behavior modification includes self-monitoring stimulus control Reinforcement techniques cognitive restructuring While on the diet, pts must be taught to modify their eating and exercise habits and lifestyle behavior. Behavior modification includes self-monitoring (food diary & exercise logs), stimulus control (remove from toxic food environment. Control environment and focus on lifestyle changes). Reinforcement, and cognitive restructuring. Reinforcement techniques: reward changes in behavior, not weight; reward behavior with something other than food; receive reward immediately after completing behavioral goal. Exercise core component: incorporate resistance to preserve LBM and RMR). Long term commitment and support (pts should commit for at least 1 year which includes both wt loss & maintenance)

70 Monitor body composition during weight loss
Weight loss results in LBM loss Subsequent decrease in resting metabolism (RMR) During aging, muscle mass lost; replaced by fat Sarcopenic obesity: BMI ≤27; body fat >30% Critical to monitor body composition throughout weight loss; especially so in older adults who are prone to sarcopenia: loss of muscle mass with age (older adults are becoming more obese while losing more muscle and bone mass at the same time). Diet-induced wt loss may accelerate loss of muscle mass. Moderate aerobic exercise attenuates loss of LBM (lean muscle mass). Chomentowski et al. Sarcopenic obesity: BMI ≥ 27:BF > 30% Guidelines vary (American Council on Exercise, American Dietetics Association, Am College of Sports Medicine) ; The American College of Sports Medicine considers a healthy body fat range for men between 8–22% and for women between 20–35%. athletes lower; % BF increases with aging. (Essential Fat women 10-12%; athletic percent); men: 2-4% essential fat; athletes 6-13 percent Kushner essential fat makes up 3–5% of total body fat in men and 8–12% of total body fat in women.1 Non-essential fat accumulates in two principle compartments: the subcutaneous and visceral adipose tissue depots.

71 Body composition: fat & fat free mass
Body fat Body composition=fat and fat-free mass. Fat-free mass includes bone, water, muscle, and tissues. Simplistically divide into 2 compartments: % fat and % lean body mass (muscle) aging

72 Monitor body composition during weight loss
Resistance training effective in preserving LBM and RMR during wt loss with VLCD Wt loss in older adults can significantly reduce LBM; attenuated by moderate aerobic activity Bryner RW, et al. J Am Coll Nutr. 1999;18(2):115-21 Critical to monitor body composition throughout weight loss; especially so in older adults who are prone to sarcopenia (older adults are becoming more obese while losing more muscle and bone mass at the same time). Diet-induced wt loss may accelerate loss of muscle mass. Moderate aerobic exercise attenuates loss of LBM (lean muscle mass). Chomentowski et al. Sarcopenic obesity: BMI ≥ 27:BF > 30% Chomentowski P, et al. J Gerontol A Biol Sci Med Sci 2009;64(5);575-80

73 Methods to measure body composition
Hydrostatic (underwater) weighing Skinfold measurements Bioelectrical Impedance Analysis (BIA) Air displacement (Bod Pod) Dual energy x-ray absorptiometry (DEXA) Infrared interactance (battery-powered, computerized infrared spectrophometer) used at some health clubs and weight loss clinics; inferior and not recommended for determining body composition

74 Skinfold limitations Error rate 5-10%
May be difficult in obese patients Hard to locate proper site Skinfold may be too large for caliper Reliability of measurements in obese unknown; not accurate in extremely obese Blackburn,G. Ed., Obesity Pathophysiology Psychology and Treatment Inexpensive. Not as accurate as the BOD POD, hydrostatic weighing, or DXA: 5–10% precision (error rate) depending on the test administrator’s skill (error factor of ±8% fat), since only subcutaneous fat is being measured. Reliability is highly dependent upon the type of calipers used and the skill level of the technician. Not a valid method for measuring the extremely obese. Testing can take a long time, as many sites need to be pinched repeatedly to achieve the most accurate results.

75 Bioelectrical Impedance Analysis (BIA)
Painless electrical current; instrument measures resistance The more water, the easier the current passes through Muscle holds more water (greater conductivity) More fat, higher resistance Calculates body water, fat-free mass and body fat % Bioelectrical Impedance Analysis (BIA): uses electrical conductance to assess body composition (3 compartments: fat, fat-free mass, and water). a small, painless electrical current is conducted through the body. The impedance analyzer measures the resistance to the signal as it travel's through the body's water, found in muscle and fat. The more muscle a person has, the more water he or she can hold. The more water within the body, the easier a current can pass through. Therefore, a person who is more muscular will have smaller electrical resistance values. A person with more fat on his or her body will have higher electrical resistance values Fat-free mass (muscle) has greater electrical conductivity than fat mass.

76 Bioelectrical Impedance Analysis (BIA)
More accurate than skinfold measurements: Affected by hydration: -Dehydration increases resistance, overestimates body fat -Pedal edema may decrease resistance, underestimate body fat Contraindicated for pacemakers, defibrillators error rate 4% Error rate 4%. Dehydration will (increase resistance) overestimate body fat, whereas pedal edema may decrease resistance and underestimate body fat. 3 compartments: fat, fat-free mass, and water Total body water (TBW) is an estimate of total hydration level, including intracellular and extracellular water. TBW is measured indirectly using dilution techniques. The traditional measures of body composition testing are based on the premise that total body weight is the sum of two categories: fat mass and fat-free mass (FFM). Direct measures of FFM, total body water, or body density are used along with total body weight to estimate the absolute and relative amount of body fat. In the last decade, more sophisticated methods have been developed to separate total body weight into a four-compartment model: fat mass, body cell mass, extracellular water, and skeletal (muscle) mass.

77 BIA These devices are moderate in price. Tanita TBF-300A Body Composition Analyzer:440 lb; (200 kg) Tanita

78 Ending VLCD: refeeding
When close to goal, start transitioning out of ketosis (typically over 2-6 weeks) Balanced LCD during maintenance Continued support Use of partial MRs improves long term results I continue VLCD until patient is at goal, then transition (will lose wt during transition: by end, just under 1000 cal). I transition over 2-3 weeks; add new food group every 3-4 days. (pts should commit for at least 1 year which includes both wt loss & maintenance)

79 Meal Replacements facilitate maintenance of weight loss
Partial meal replacement: replacing one or two meals daily improves long-term weight control Fabricatore (2004) MRs are viable and cost-effective for weight loss and maintenance in T2DM Hamdy and Zwiefelhofer (2010) MR central tool; very effective for maintenance & long-term weight control as well. Research-based; over a million patients; documented outcomes. Control portions and calories; provide structure, eliminate decision-making and guessing; improve nutrition Stimulus control: remove from toxic food environment. MR is any prepackaged food product that is portion controlled, calorie controlled, and high nutrition; Typically <300 cal, g protein, g CHO, < 9 g fat Portion control is one of the biggest factors in successful weight loss 79

80 What happens after weight loss?
Metabolic adaptations occur Neuroendocrine changes convey “energy deficit signal” Decreased leptin, peptide YY, cholecystokinin, insulin, amylin (anorexigenic) Increased ghrelin, GIP, pancreatic peptide (oxeigenic), subjective appetite MacLean et al; (rat studies) Factors contributing to weight regain include: Reduced resting energy expenditure (REE); Reduction in leptin (anorexigenic) and insulin; Increase in ghrelin (orexigenic); The obesogenic environment. Weight loss produces compensatory metabolic responses and a physiologic and hormonal drive to regain, which are attenuated by high levels of activity. in a 10-week weight-loss program for which a very-low-energy diet was 50 overweight or obese patients without diabetes prescribed. At baseline (before weight loss), at 10 weeks (after program completion), and at 62 weeks, we examined circulating levels of leptin, ghrelin, peptide YY, gastric inhibitory polypeptide, glucagon-like peptide 1, amylin, pancreatic polypeptide, cholecystokinin, and insulin and subjective ratings of appetite. One year after initial weight reduction, levels of the circulating mediators of appetite that encourage weight regain after diet-induced weight loss do not revert to the levels recorded before weight loss. Weight loss (mean [±SE], 13.5±0.5 kg) led to significant reductions in levels of leptin, peptide YY, cholecystokinin, insulin (P<0.001 for all comparisons), and amylin (P=0.002) and to increases in levels of ghrelin (P<0.001), gastric inhibitory polypeptide (P=0.004), and pancreatic polypeptide (P=0.008). There was also a significant increase in subjective appetite (P<0.001). One year after the initial weight loss, there were still significant differences from baseline in the mean levels of leptin (P<0.001), peptide YY (P<0.001), cholecystokinin (P=0.04), insulin (P=0.01), ghrelin (P<0.001), gastric inhibitory polypeptide (P<0.001), and pancreatic polypeptide (P=0.002), as well as hunger (P<0.001). N ENGL J MED 2011; 365: ; October 27, 2011 Sumithran et al; NEJM 2011;365; Oct 27, 2011 80

81 What happens after weight loss?
Increased drive to eat Decreased energy expenditure/REE = large energy gap between appetite and expenditure + Factors contributing to weight regain include: Reduced resting energy expenditure (REE); Reduction in leptin (anorexigenic) and insulin; Increase in ghrelin (orexigenic); The obesogenic environment. Weight loss produces compensatory metabolic responses and a physiologic and hormonal drive to regain, which are attenuated by high levels of activity. in a 10-week weight-loss program for which a very-low-energy diet was 50 overweight or obese patients without diabetes prescribed. At baseline (before weight loss), at 10 weeks (after program completion), and at 62 weeks, we examined circulating levels of leptin, ghrelin, peptide YY, gastric inhibitory polypeptide, glucagon-like peptide 1, amylin, pancreatic polypeptide, cholecystokinin, and insulin and subjective ratings of appetite. One year after initial weight reduction, levels of the circulating mediators of appetite that encourage weight regain after diet-induced weight loss do not revert to the levels recorded before weight loss. Weight loss (mean [±SE], 13.5±0.5 kg) led to significant reductions in levels of leptin, peptide YY, cholecystokinin, insulin (P<0.001 for all comparisons), and amylin (P=0.002) and to increases in levels of ghrelin (P<0.001), gastric inhibitory polypeptide (P=0.004), and pancreatic polypeptide (P=0.008). There was also a significant increase in subjective appetite (P<0.001). One year after the initial weight loss, there were still significant differences from baseline in the mean levels of leptin (P<0.001), peptide YY (P<0.001), cholecystokinin (P=0.04), insulin (P=0.01), ghrelin (P<0.001), gastric inhibitory polypeptide (P<0.001), and pancreatic polypeptide (P=0.002), as well as hunger (P<0.001). N ENGL J MED 2011; 365: ; October 27, 2011 MacLean et al; 2009 Sumithran et al; NEJM 2011;365; Oct 27, 2011 81

82 Physical activity (PA) is critical for long-term weight management
Best predictor of weight maintenance Add resistance to preserve LBM and RMR Resistance training won’t promote clinically significant weight loss: energy expenditure is not large, but muscle mass may increase, increasing BMR Am College Sports Medicine Position Stand 2009 Likely that individuals vary in their response to PA for prevention of wt gain, for wt loss and for wt maintenance. Inability to sustain weight loss mirrors the inability to sustain physical activity. Need to preserve LBM, especially in older patients (aging causes decrease in LBM). 82

83 PA is critical for long-term weight management
Level of physical activity to sustain weight loss double the public health recommendation of 30 minutes moderate-intensity activity most days Maintaining wt loss requires at least 1,800 kcal/wk Optimum long-term control: kcal exercise weekly (walking miles) Jakicic JM, Marcus BH, Janney C. Arch Intern Med 2008;168: NWCR: wt maintenance is improved with PA > 250 min/wk. double amount of exercise compared to surgical patients. For optimum long-term control, kcal exercise weekly (walking miles) Wadden, Butryn Gastroenterology 2007 Jakicic JM, Marcus BH, Lang W, Janney C. Effect of Exercise on 24-Month Weight Loss Maintenance in Overweight Women. Arch Intern Med. 2008;168(14): John Jakicic, U. of Pittsburgh’s Physical Activity and Weight Management Research Center. Wt maintenance is improved with PA > 250 min/wk. double amount of exercise compared to surgical patients Wadden TA, Butryn ML, Wilson C. Gastroenterology 2007;132:

84 Lifestyle (unstructured) activity
Associated with better adherence than programmed exercise Less structured activity (Non-Exercise Activity Thermogenesis; NEAT) associated with less weight regain. Wadden TA, Butryn ML, Wilson C. Gastroenterology 2007;132:

85 Predictors of Success Commitment Motivation Regular exercise
Effective stress control Good social support Realistic goal setting Focus on health rather than weight Rapid weight loss Intensive program; requires motivation and commitment. If ready to make changes, will have excellent results Goals should be specific and measurable; begin with small changes that are sustainable. the 5 P’s are critical. Does the goal or experiment that you are setting up with the pt meet all 5? If not, it should be modified. “I’m going to eat better” is not precise. Set specific small changes that the pt feels are possible this week. Are they likely to be issues that are of current concern to the patient? If not, they will not happen.

86 Anderson et al; Am J Clin Nutri 2001;74 (meta-analysis of 29 studies)
Faster weight loss produces better results VLCDs produce greater weight loss and better long term maintenance than LCDs Anderson et al; Am J Clin Nutri 2001;74 (meta-analysis of 29 studies) 2001 meta-analysis Twenty-nine studies. Successful very-low-energy diets (VLEDs) were associated with significantly greater weight-loss maintenance than were successful hypoenergetic balanced diets (HBDs) at all years of follow-up. James W Anderson, Elizabeth C Konz, Robert C Frederich, and Constance L Wood. Long-term weight-loss maintenance: a meta-analysis of US studies. Am J Clin Nutr 2001;74:579–84

87 Rate of initial weight loss important predictor of long-term success
More weight lost & better long-term maintenance Nackers et al, Int J Behav Med 2010;17: Rapid weight loss (VLCD) works significantly better than gradual (motivation; ketosis) Zoler, Family Practice News ; 9/1/10 Some recent studies showing that rapid weight loss produces significantly better results than slow (motivation, ketogenesis), JUMPSTART; long term advantage to faster initial wt loss; did not result in weight regain. Often stated that the faster weight is lost, the faster it is regained; the reverse is true. Promote early success; catalyst for lifestyle change. large behavioral changes in initial weeks rather than small

88 Rate of initial weight loss
Common belief that slow weight loss produces better results is not correct greater initial weight loss results in improved sustained weight maintenance providing it is followed by a 1-2 years integrated weight maintenance programme ( lifestyle interventions involving dietary change, nutritional education, behaviour therapy and increased physical activity) Astrup A, Rössner S. Lessons from obesity management programmes: greater initial weight loss improves long-term maintenance. Obes Rev May;1(1):17-9. Astrup & Rossner; Obes Res. 2000;1:17-19

89 Conclusion: VLCDs Easy for patients; produce rapid weight loss; safe when done under experienced staff Meal replacements, rapid weight loss and early success all produce better long-term results Intervention must include diet, physical activity, behavior modification, long-term support Sustainable lifestyle modification is the key to successful weight loss in the long term Weight management requires a lifelong commitment to healthy lifestyle behaviors; The best regimen for overall health and weight management is that which is most sustainable. Lifestyle modification is the key to successful weight loss in the long term

90 Obesity is a chronic disease
Optimally treated using a chronic care model and Intensive lifestyle modification Pts must be taught to modify their eating and exercise habits and lifestyle behavior Physical activity (PA) is critical; add resistance to preserve LBM and RMR Longitudinal support. pts must be taught to modify their eating and exercise habits and lifestyle behavior (intensive lifestyle modification). Behavior modification includes self-monitoring (food diary & exercise logs), stimulus control (remove from toxic food environment. Control environment and focus on lifestyle changes). reinforcement, and cognitive restructuring. Exercise core component: incorporate resistance to preserve LBM and RMR). Long term commitment and support (pts should commit for at least 1 year which includes both wt loss & maintenance)

91 Provide comprehensive lifestyle program
Focus on long-term healthy behaviors: Customized eating plan with calorie deficit Activity plan that gradually increases Maintenance plan Lifestyle program, focusing on long-term healthy behaviors. The best regimen for overall health and weight management is that which is most sustainable. Cornerstone of therapy. Focus on health rather than weight; incorporate healthy behaviors and permanent lifestyle change; continuous process rather finite weight loss. Healthy weight BMI < 30. provide individualized nutritional and behavioral intervention, education, and long-term support. Focus on a long-term healthy lifestyle: regular physical activity; good nutrition; patterns ; maintaining a healthy weight; balance calories consumed with calories burned


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