Transcript Very Low Calorie Diets in Clinical Practice

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
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
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
Insulin inhibits lipolysis in adipocytes
turns off lipolysis
& ketogenesis
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
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
Meal replacements (MRs)
Why are they so effective?
Improved
nutrition
Portion control
Calorie control
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
Toxic environment
Cars are the new
dining room!
Car Swivel Saucer
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
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
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
Todd & Mancino 2010; Neil et al; 2008
• 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
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
Calorie Confusion
• Only 9% of Americans can accurately estimate the
number of calories they should consume in a day
i.e. energy balance
• 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
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
Energy balance
• Weight management requires knowing calorie
(energy) requirements and balance
• Almost impossible when eating out regularly
Appetizer:
9 Onion Rings
900 calories!
Dinner:
Cheeseburger
And Fries
Chicken Finger
Dinner
1,440
Calories!
1,640
Calories!
Source: Nutrition Action Healthletter, October 1996
Bloomin’ Onion: 2,210 calories, 160 g fat
Dinner
½ Blooming onion
1,100 calories, 80 g fat
½ Cheese Fries
1,100 calories, 79 g fat
+
Outback Special
Calories: 1410; fat 77g
Chicken Caesar Salad
907 calories, 60 g fat
Cheesecake Factory chicken and biscuits:
2500 calories
Applebee’s Quesadilla Burger:
1820 calories, 46 grams sat fat
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!
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
2,000 Calories!!!
Inactive lifestyle, poor nutrition,
calorie imbalance
obesity
The bigger the portion, the more one eats!
Bottomless bowl
• Self-refilling bowl
• Consumed 73% more
• Did not believe that
they ate more
• Did not feel more full
Wansick et al (2005)
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.”
Wadden TA, Butryn ML, Byrne KJ. Obes Res 2004;12:151S-161S.
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
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
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%
Wadden, West, et al. Obesity 2009;17(4):713-722.
• MR are viable and cost-effective for weight loss
and maintenance in T2DM
Hamdy O, Zwiefelhofer D. Curr Diab Rep. 2010;10:159-164
MR diet more effective in reducing
metabolic risk factors, insulin & leptin than fatrestricted low-calorie diet
Konig D, et al. Ann Nutr Metab 2008;52:74-78
“Overweight patients
should be encouraged
to use MR/portioncontrolled diets”
Bray G. Am Fam Physician 2010;81:1406-1408
• 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
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
Meal replacements (MRs)
• Convenient; cost-effective
• Healthy alternative to skipping meals
• Provides structure to eating plan; reduces
anxiety over making food choices
• Compliance improved
MRs displace calories & poor
nutrition
Example:
Typical Meal
Breakfast
Dinner
Sausage biscuit
510 calories
Meal Replacement
Shake:
Approx. Savings
400 cals.
100 cals.
Dinner:
Shake + bar or lean meal
1550 cals.
260 cals.
1300 cals.
Using two meal replacements saves 1700 cal.
1700 cal ≈ walking 17 miles (about 5 hours)
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
Definition of Very Low Calorie
Diets (VLCDs)
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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
History of VLCDs
• Present since 1929
• Reintroduced 1970s (Blackburn) proteinsparing 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 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
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;
< 25% LBM; >75% fat mass
• Rapid weight loss boosts motivation and
produces better results
• Multidisciplinary approach: behavior, nutrition,
exercise (aerobic and resistance)
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
VLCDs: patient selection
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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
Medical monitoring
• Obesity workup:
– history, including weight history, PE
– EKG, CMP, FLP, CBC, TSH, UA, (A1c*)
– Body composition; measurements
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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
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)
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
Side effects
symptom
• Muscle cramps
• Dizziness; orthostasis
• Constipation
• Halitosis
• Hair loss
• Dry skin
treatment
• 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
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)
•3-8% with current VLCDs ( ~ 800 cal; ≥10 g fat)
• Ursodeoxycholic acid (Actigall) 600 mg daily optimum for
prophylaxis
Shiffman ML, et al. Ann Intern Med 1995;122:899-905
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
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
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
Baker et al; Diabetes Res Clin Pract. 2009
Obesity significant risk for NAFLD
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
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
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
VLCD 16 weeks in 12 obese
T2DM patients
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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
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
VLCD protocols using products
• Complete (all products)
• Modified (partial products)
• Numerous variations are possible
• Customize your approach for patient
preference and optimal success
Nutritional parameters
• Adequate protein (at least 75 g high quality)
• Calories ~800 g daily
• CHO ≤ 50 g daily
• Fluid: minimum 64 ounces daily
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)
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•
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2 bars, 3 shakes
2 bars, 4 shakes (most common)
1 bar, 4 shakes
3 bars, 2 shakes
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
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
+ 2 protein bars
30 g protein, 14 CHO, 200 cal
+ 1 Lean meal
30 g protein, 26 CHO,
320 calories
28-32 g protein, 10 CHO
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
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
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
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
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%
Body composition:
fat & fat free mass
Body fat
aging
Monitor body composition during weight loss
• Resistance training effective in preserving
LBM and RMR during wt loss with VLCD
Bryner RW, et al. J Am Coll Nutr. 1999;18(2):115-21
• Wt loss in older adults can significantly
reduce LBM; attenuated by moderate
aerobic activity
Chomentowski P, et al. J Gerontol A Biol Sci Med Sci 2009;64(5);575-80
Methods to measure body
composition
• Hydrostatic (underwater) weighing
• Skinfold measurements
• Bioelectrical Impedance Analysis (BIA)
• Air displacement (Bod Pod)
• Dual energy x-ray absorptiometry (DEXA)
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
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)
• More accurate than skinfold measurements:
error rate 4%
• Affected by hydration:
-Dehydration increases resistance,
overestimates body fat
-Pedal edema may decrease resistance,
underestimate body fat
• Contraindicated for pacemakers, defibrillators
BIA
Tanita
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
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)
What happens after weight loss?
• Metabolic adaptations occur
• Neuroendocrine changes convey “energy
deficit signal”
MacLean et al; 2009 (rat studies)
– Decreased leptin, peptide YY, cholecystokinin,
insulin, amylin (anorexigenic)
– Increased ghrelin, GIP, pancreatic peptide
(oxeigenic), subjective appetite
Sumithran et al; NEJM 2011;365; Oct 27, 2011
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
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
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
Jakicic JM, Marcus BH, Janney C. Arch Intern Med 2008;168:1550-1560
• Optimum long-term control: 2500-3000 kcal exercise
weekly (walking 25-30 miles)
Wadden TA, Butryn ML, Wilson C. Gastroenterology 2007;132:2226-2238
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
Predictors of Success
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Commitment
Motivation
Regular exercise
Effective stress control
Good social support
Realistic goal setting
Focus on health rather than weight
Rapid weight loss
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)
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
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
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
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
Provide comprehensive lifestyle
program
• Focus on long-term healthy behaviors:
• Customized eating plan with calorie deficit
• Activity plan that gradually increases
• Maintenance plan