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Very Low Calorie Diets (VLCDs) in Clinical Practice How to Use the VLCD with Supplements

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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 Society of Bariatric Physicians; Las Vegas, Nevada; November, 2011. Joan Temmerman, MD, MS, FAAFP, CNS. - PowerPoint PPT Presentation
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  • Very Low Calorie Diets (VLCDs) in Clinical PracticeHow 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, CNSMedical 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 & insulinDietary 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 restrictionKetones 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 ketosisShift 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?Portion controlCalorie controlImproved nutrition

  • 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 availableWe live in an obesogenic society

  • Toxic environment

  • Cars are the new dining room!Car Swivel Saucer

  • Eating out is associated with obesity50% 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, 19402004. Sources: Flegal et al.& Ogden et al; USDA Food Expenditure Tables.Neil et al, Am J Prev Med. 2008 February ; 34(2): 127133

  • 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

  • Obesity risk not affected by the type of restaurantConsumers 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 superiorhigher 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

    Half of Americans are unable to estimate how many calories they burn in a day

    Most Americans dont track calories consumed or burned citing numerous barriers, including extreme difficulty & lack of interest, knowledge, and focusIFIC Foundation Releases 2011 Food & Health Surveyi.e. energy balance

  • The American Lifestyle 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 disappeared40% 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 Rings900 calories!

  • Bloomin Onion: 2,210 calories, 160 g fat

  • Dinner Blooming onion1,100 calories, 80 g fat Cheese Fries 1,100 calories, 79 g fat Chicken Caesar Salad 907 calories, 60 g fatOutback Special Calories: 1410; fat 77g

    +

  • Cheesecake Factory chicken and biscuits: 2500 calories

  • Applebees Quesadilla Burger: 1820 calories, 46 grams sat fat

  • Cheesecake Factory fried Macaroni and Cheese: 1570 calories, 69 grams sat fat800 calories, 57 g sat fat

    More saturated fat than a whole stick of butter!

  • Cold Stone Creamery Lotta Caramel Latte 1,800 calories90 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 bowlSelf-refilling bowl

    Consumed 73% more

    Did not believe that they ate more

    Did not feel more full

    Wansick et al (2005)

  • 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 studiesLi Z, Bowerman S, Heber D. Obes Manag 2006;2(1): 23-28Wadden TA, Butryn ML, Byrne KJ. Obes Res 2004;12:151S-161S. Portion control is a main factor in successful weight loss

  • 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%

    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

  • Overweight patients should be encouraged to use MR/portion-controlled diets

    Bray G. Am Fam Physician 2010;81:1406-1408MR diet more effective in reducing metabolic risk factors, insulin & leptin than fat-restricted low-calorie dietKonig D, et al. Ann Nutr Metab 2008;52:74-78

  • MR: prepackaged food product that is portion controlled, calorie controlled, & high nutrition

  • 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

  • Convenient; cost-effective

    Healthy alternative to skipping meals

    Provides structure to eating plan; reduces anxiety over making food choices

    Compliance improved

    Meal replacements (MRs)

  • MRs displace calories & poor nutritionUsing two meal replacements saves 1700 cal. 1700 cal walking 17 miles (about 5 hours)BreakfastDinnerMeal ReplacementApprox. SavingsSausage biscuit 510 calories Shake:100 cals.400 cals.Dinner:1550 cals.Shake + bar or lean meal260 cals.1300 cals.Example:Typical Meal

  • Meal replacements in VLCDsMR 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)400-800 kcal/day; ~800 calories favored~80-100 g high quality proteinCHO restricted; nutritional ketosisVLCD 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 VLCDsPresent since 1929

    Reintroduced 1970s (Blackburn) protein-sparing modified fast (PSMF)

    Last Chance Diet (liquid protein): late 70s low-quality protein (hydrolyzed collagen)No vitamin/mineral supplementationNo medical supervision 60 deaths (cardiac)

  • VLCDs today Safe under experienced supervisionMedical 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 todayRapid weight loss: 3-3.5 # week F; 5 # wk M Most patients will lose 40-44 # in 12-16 wksHeavier 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 todayHighly structured intervention

    Typically commercial MR products used (total or partial food replacement)

    MRs increase adherence and weight loss

    Remove from food environment

  • VLCDs: patient selectionBMI 27 with co-morbidities; 30 withoutRapid weight lossHighly motivatedMedical 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 monitoringObesity workup: history, including weight history, PE EKG, CMP, FLP, CBC, TSH, UA, (A1c*)Body composition; measurements

    Weekly*/biweekly monitoring: BP, HR, weightLytes q2-4 wks; FLP (A1c) q 3monthsBody compositionEKG every 30-50 # wt loss

    *regular f/u essential; complicated patients wkly

  • Medical monitoringHold 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 adjustmentMonitor medications whose serum levels must be closely followed (coumadin, theophylline , etc)

  • Side effectsMinor & 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 effectsMuscle crampsDizziness; orthostasisConstipation

    Halitosis

    Hair loss Dry skin

    Slow-Mag (OTC) lytesSodium (bouillon) BP Fluids, sugar-free fiber daily, MOM prnListerine strips, sugar & CHO-free mints/gumReassurance; biotinEFAs (fish oil); lotion

    symptomtreatment

  • GallstonesLinear 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; 13 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

  • Health benefits: immediate & dramaticRapidly 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

  • DiabetesIn general, diabetic patients may find it harder to lose weight:Medications: insulin, TZDs, sulfonylureas Increased food to avoid hypoglycemiaInflammation; adipokines, insulin resistance

  • VLCDs: profound effect on glycemic controlRapid 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 NAFLDTransient 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 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 increasedSignificant reduction in fat stores

    Hammer S, Snel M, et al. JACC. 2008

  • 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 < 0.001Hammer et al. JACC 2008Fat stores and VLCDs

  • VLCD protocols using productsComplete (all products)

    Modified (partial products)Numerous variations are possibleCustomize your approach for patient preference and optimal success

  • Nutritional parametersAdequate 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 MRbars (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

  • Modified VLCD: lean meal3-4 oz. lean protein7-9 g protein/oz 25-50 calories/oz

    2 non-starchy vegetables(no potatoes, peas, corn, ?carrots)25 calories/serving5 g CHO/serving

  • Modified VLCD: 1 lean meal + 4 MR2 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 shakes30 g protein, 14 CHO, 200 cal 2 protein bars30 g protein, 26 CHO,320 calories 1 Lean meal28-32 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 bar15 g protein, 13 CHO,160 calories 1 Lean meal28-32 g protein, 10 g CHO++

  • Modified VLCD variations1 lean meal + 3 MR; all bars

    3 protein bars 45 g protein, 39 CHO, 480 calories

    1 Lean meal28-32 g protein, 10 g CHO+

  • Modified VLCD variations2 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 changesVLCDs 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 techniquescognitive restructuring

  • Monitor body composition during weight lossWeight 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 massBody fataging

  • Monitor body composition during weight lossResistance 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):115-21Chomentowski P, et al. J Gerontol A Biol Sci Med Sci 2009;64(5);575-80

  • Methods to measure body compositionHydrostatic (underwater) weighing

    Skinfold measurements

    Bioelectrical Impedance Analysis (BIA)

    Air displacement (Bod Pod)

    Dual energy x-ray absorptiometry (DEXA)

  • Skinfold limitationsError 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: Affected by hydration: -Dehydration increases resistance, overestimates body fat -Pedal edema may decrease resistance, underestimate body fat

    Contraindicated for pacemakers, defibrillatorserror rate 4%

  • BIA Tanita

  • Ending VLCD: refeedingWhen 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 lossPartial 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

    Decreased leptin, peptide YY, cholecystokinin, insulin, amylin (anorexigenic)Increased ghrelin, GIP, pancreatic peptide (oxeigenic), subjective appetiteMacLean et al; 2009 (rat studies)

    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 expenditureMacLean 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 RMRResistance training wont 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 managementLevel 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;168:1550-1560Wadden 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 CommitmentMotivationRegular exerciseEffective stress control Good social supportRealistic goal settingFocus on health rather than weightRapid weight loss

  • VLCDs produce greater weight loss and better long term maintenance than LCDsAnderson et al; Am J Clin Nutri 2001;74(meta-analysis of 29 studies)Faster weight loss produces better results

  • Rate of initial weight loss important predictor of long-term success More weight lost & better long-term maintenanceNackers 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 lossCommon 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: VLCDsEasy 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 diseaseOptimally 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

    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

    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 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. 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. 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 (

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