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?
Portion control
Calorie control
Improved 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 available
We live in an obesogenic society
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
• 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 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, sodiumStewart 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 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
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
Dinner: Chicken Finger
DinnerCheeseburger
And Fries
1,440 Calories!
1,640 Calories!
Appetizer: 9 Onion Rings
900 calories!
Source: Nutrition Action Healthletter, October 1996
Bloomin’ Onion: 2,210 calories, 160 g fat
Dinner
½ Blooming onion1,100 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
+
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
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)
“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
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;81:1406-1408
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
• 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
• 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 nutrition
Using two meal replacements saves 1700 cal.
1700 cal ≈ walking 17 miles (about 5 hours)
Breakfast
Dinner
Meal Replacement Approx. 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
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)
• 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) 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 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
• 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
• 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
• 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
symptom treatment
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
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 improvedBlackburn & 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
• 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
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
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)
• 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 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 variations
1 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 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
• 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
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:
• Affected by hydration: -Dehydration increases resistance,
overestimates body fat -Pedal edema may decrease resistance,
underestimate body fat
• Contraindicated for pacemakers, defibrillators
error rate 4%
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”
– 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
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 RMRResistance 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
• 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
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
• Commitment• Motivation• Regular exercise• Effective stress control • Good social support• Realistic goal setting• Focus on health rather than weight• Rapid weight loss
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
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 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
