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

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.

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

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  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

  3. 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

  4. Insulin inhibits lipolysis in adipocytes turns off lipolysis & ketogenesis

  5. 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

  6. 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

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

  8. Obesity not just an issue of personal responsibility2/3 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

  9. Toxic environment

  10. Cars are the new dining room! Car Swivel Saucer

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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 burnedciting numerous barriers, including extreme difficulty & lack of interest, knowledge, and focus i.e. energy balance IFIC Foundation Releases 2011 Food & Health Survey

  16. The American Lifestyle ½ of US food budget is spent eating outside the homeClauson & Leibtag,USDA 2011 Only 9% keep track of caloriesand can accurately estimate how many calories they should eat Physical activity has disappeared 40% of adults get no activity at all

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

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

  19. Bloomin’ Onion: 2,210 calories, 160 g fat

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

  21. Cheesecake Factory chicken and biscuits: 2500 calories

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

  23. 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!

  24. Cold Stone CreameryLotta Caramel Latte 1,800 calories 90 g fat; 57 g saturated (~ 57 strips bacon) • 175 g sugar: 44 tsps • ~ 1 cup sugar

  25. 2,000 Calories!!!

  26. Inactive lifestyle, poor nutrition, calorie imbalance obesity

  27. The bigger the portion, the more one eats!

  28. Bottomless bowl Self-refilling bowl Consumed 73% more Did not believe that they ate more Did not feel more full Wansick et al (2005)

  29. 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.” 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.

  30. 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

  31. 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

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

  33. 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

  34. 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

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

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

  37. 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

  38. 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

  39. 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)

  40. VLCDs todaySafe 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

  41. 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)

  42. 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

  43. 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

  44. 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

  45. 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)

  46. 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 qhsfor prophylaxis) Diuresis; natriuresis; kaliuresis

  47. 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

  48. 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

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