1. Low Calorie Liquid Diet (LCLD) Pilot Gillian Clarke - Clyde Team Lead/Advanced Dietitian October 2013

2. Rationale behind LCLD Eating less leads to weight loss. Having the choice at mealtimes/snacks can be very difficult for some to control their intake. Requires more effort for example weighing out food/counting portions.

3. LCLD Pilot – Aims To improve adherence to a recommended calorie prescription by removing food choices and replacing food with liquids. To achieve a 10kg minimum weight loss over a 12 week period. To measure the effect of liquid diet induced weight loss on patients’ mood/quality of life and eating behaviours. To support patients with reintroducing food.

4. Why use liquid meal replacements for weight loss? Evidence shows use of liquid MR as part of a calorie-controlled diet is an effective strategy for long-term maintenance of weight loss as well as the promotion of short-term weight loss compared with a traditional reduced calorie diet. (Ashley et al. 2001)

5. Why use liquid meal replacements for weight loss? Provides a structured eating pattern. Easy to follow. Makes it easier to plan and prepare meals. Removes food choices – improve accuracy of energy intake. Patients can often under estimate their calorie intake (Samaras et al, 1999; Mertz et al, 1991). Can improve nutritional adequacy (vitamins and minerals).

6. Use within GCWMS Additional intensive treatment option as part of specialist service. To support patients in following a low calorie diet by removing food choices and being in a liquid form. To promote motivation to engage with the programme due to good weight losses. Change in surgery criteria - LCLD may be an ‘alternative’ to surgery for those not eligible.

7. Exclusions Any patients who had completed phase 1 and whose BMI <30kg/m 2. Patients with diabetes on medications other than Metformin. No evidence to exclude patients with disordered eating/binge eating. Upper age limit consideration - <70yrs old for pilot.

8. Recruitment Patients were recruited from groups having completed at least phase 1 of the programme. Patients attended an information session on the LCLD pilot. Written consent obtained from all participants.

9. Pilot Design Patients energy requirements calculated and they were provided with a 1200 calorie deficit diet. LCLD plans were 1000/1200/1500 calories. Plans devised from over the counter meal replacements and a homemade version which patients had to self- purchase. All plans were nutritionally analysed considering protein, vitamins, minerals and fibre content against recommended amounts for adults.

11. Some individual patient results Patient Weight at start of LCLD (kg) Weight after 12 weeks on LCLD (kg) Female (66yrs) 1000 calorie liquid diet 109.891.4 Male (56yrs) 1500 calorie liquid diet 206.3185.3 Male (52yrs) 1500 calorie liquid diet 128.8113.3 Female (48yrs) 1200 calorie liquid diet 120.5100.3

12. Patient feedback “I feel a lot better a lot healthier, lost weight and surprised myself.” “Big improvements, not tired, feeling good and being very active.” “Ability to control what I eat, listening to my body to find out if I'm actually hungry.” “I have more will power than I realised. A lot of my eating is just for the sake of it.”

13. Food reintroduction phase (16 weeks) Gradually reintroduced one meal at a time, revisiting portion guide as covered in phase 1 of programme. Continuing on at least a 600 calorie deficit diet. Aiming to return to a healthy balanced calorie-controlled diet.

14. LCLD Pilot results – Food reintroduction phase FR completers at 28wks (n=10) Wt loss in prog prior to LCLD trial (kg) 6.0 + 6.3 LCLD weight loss (kg) 12.9 + 6.5 Food Reintroduction Weight Loss (kg) +1.3 + 3.8

16. Next stage - ongoing Patients currently in the weight maintenance phase of the programme. Preliminary results at 1 year post LCLD mean weight loss of 7.7kgs maintained (8/12 patients still in the programme).

17. Evaluation Range of outcomes being collected including: - weight loss - weight regain - weight maintenance. Psychologists have developed psychology assessments using QEWP-R, HADS, QOL questionnaires throughout LCLD phase for quantitative results. Qualitative data will also be gathered.

18. Research Poster of findings exhibited at European Congress on Obesity, Liverpool (May 2013). Also exhibited at AHP National Conference, Edinburgh (October 2013).