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Very Low Calorie Diets (VLCDs) in Clinical Practice How to Use the VLCD with Supplements 61st Annual Obesity & Associated Conditions Symposium; American.

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Presentation on theme: "Very Low Calorie Diets (VLCDs) in Clinical Practice How to Use the VLCD with Supplements 61st Annual Obesity & Associated Conditions Symposium; American."— Presentation transcript:

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

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


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

5 Insulin inhibits lipolysis in adipocytes turns off lipolysis & ketogenesis

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


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

9 Meal replacements (MRs) Why are they so effective? Portion control Calorie control Improved nutrition

10 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 We live in an obesogenic society

11 Toxic environment

12 Cars are the new dining room! 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

14 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. 2008 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

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 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 IFIC Foundation Releases 2011 Food & Health Survey i.e. energy balance

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

19 Energy balance Weight management requires knowing calorie (energy) requirements and balance Almost impossible when eating out regularly

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

21 Bloomin’ Onion: 2,210 calories, 160 g fat

22 Dinner ½ Blooming onion 1,100 calories, 80 g fat ½ Cheese Fries 1,100 calories, 79 g fat Chicken Caesar Salad 907 calories, 60 g fat Outback Special Calories: 1410; fat 77g +

23 Cheesecake Factory chicken and biscuits: 2500 calories

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

25 Cheesecake Factory fried Macaroni and Cheese: 1570 calories, 69 grams sat fat 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

27 2,000 Calories!!!

28 Inactive lifestyle, poor nutrition, calorie imbalance obesity

29 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)

31 “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 a main factor in successful weight loss

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;59:411-418

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):713-722. Hamdy O, Zwiefelhofer D. Curr Diab Rep. 2010;10:159-164

34 “ Overweight patients should be encouraged to use MR/portion- controlled diets” Bray G. Am Fam Physician 2010;81:1406-1408 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

35 MR : prepackaged food product that is portion controlled, calorie controlled, & high nutrition <300 cal, 10-20 g protein, 10-45 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

37 Convenient; cost-effective Healthy alternative to skipping meals Provides structure to eating plan; reduces anxiety over making food choices Compliance improved Meal replacements (MRs)

38 MRs displace calories & poor nutrition Using two meal replacements saves 1700 cal. 1700 cal ≈ walking 17 miles (about 5 hours) Breakfast Dinner Meal ReplacementApprox. Savings Sausage biscuit 510 calories Shake: 100 cals. 400 cals. Dinner: 1550 cals. Shake + bar or lean meal 260 cals. 1300 cals. Example: Typical Meal

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

40 Definition of Very Low Calorie Diets (VLCDs) 400-800 kcal/day; ~800 calories favored ~80-100 g high quality protein CHO restricted; nutritional ketosis VLCD and Protein Sparing Modified Fast (PSMF) used interchangeably Low Calorie Diets (LCDs) > 800 kcal; typically 1000-1500 kcal/day 1. Ketogenic (CHO restriction) 2. balanced

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)

42 VLCDs today Safe under experienced supervision Medical monitoring mandatory (MD trained & experienced in use of VLCDs) Protein 1.2-1.5 g/kg IBW (150% of RDA) ~75-100 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

43 VLCDs today Rapid weight loss: 3-3.5 # week F; 5 # wk M – Most patients will lose 40-44 # in 12-16 wks – Heavier patients lose more Typical maximum: ~ 1/3 of TBW; 75% fat mass Rapid weight loss boosts motivation and produces better results Multidisciplinary approach: behavior, nutrition, exercise (aerobic and 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

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

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 30-50 # wt loss *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/d Anti-hypertensives may need rapid adjustment Monitor medications whose serum levels must be closely followed (coumadin, theophylline, etc)

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

49 Side effects 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 symptomtreatment

50 Gallstones 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) Shiffman ML, et al. Ann Intern Med 1995;122:899-905 3-8% with current VLCDs ( ~ 800 cal; ≥10 g fat) Ursodeoxycholic acid (Actigall) 600 mg daily optimum for prophylaxis

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 15-50 % Mood, well-being, energy level, QOL, self-esteem improved 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

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

54 Baker et al; Diabetes Res Clin Pract. 2009

55 Obesity significant risk for NAFLD

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

57 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 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 35.6 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

60 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 Fat stores and VLCDs

61 VLCD protocols using products Complete (all products) Modified (partial products) Numerous variations are possible Customize your approach for patient preference and optimal success

62 Nutritional parameters Adequate protein (at least 75 g high quality) Calories ~800 g daily CHO ≤ 50 g daily Fluid: minimum 64 ounces daily

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

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

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 ++

66 Modified VLCD variations 1 lean meal + 4 MR (3 shakes, 1 bar) 3 protein shakes 45 g protein, 21 CHO, 300 cal 1 protein bar 15 g protein, 13 CHO, 160 calories 1 Lean meal 28-32 g protein, 10 g CHO ++

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 +

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 ++

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

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%

71 Body composition: fat & fat free mass Body fat 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 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)

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., 1994. Obesity Pathophysiology Psychology and Treatment

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 %

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%

77 BIA 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

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)

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; 2009 (rat studies) Sumithran et al; NEJM 2011;365; Oct 27, 2011

81 What happens after weight loss? Increased drive to eat Decreased energy expenditure/REE = large energy gap between appetite and expenditure MacLean et al; 2009 Sumithran et al; NEJM 2011;365; Oct 27, 2011 +

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

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: 2500-3000 kcal exercise weekly (walking 25-30 miles) Jakicic JM, Marcus BH, Janney C. Arch Intern Med 2008;168:1550-1560 Wadden TA, Butryn ML, Wilson C. Gastroenterology 2007;132:2226-2238

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;132:2226-2238

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

86 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) Faster weight loss produces better results

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;17:161-167 Rapid weight loss (VLCD) works significantly better than gradual (motivation; ketosis) Zoler, Family Practice News ; 9/1/10

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 & 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

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

91 Provide comprehensive lifestyle program Focus on long-term healthy behaviors: Customized eating plan with calorie deficit Activity plan that gradually increases Maintenance plan

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