Pharmacy Diabetes

DPR-session-1-energy restriction

Very Low Energy (kilojoule/Calorie) Diets
  • The invention of Very Low Energy Diets (VLEDs) stemmed from an interest in creating a weight loss therapy that could produce outcomes comparable to starvation but without the increased risk of morbidity and mortality.
  • The precursor of VLEDs began in 1915 when high protein food-based diets of 1,700 – 2,500 kJ (400 to 600 Calorie) were used for rapid weight loss to treat people with obesity.
  • Liquid drinks comprised almost entirely of high-quality protein (milk casein or egg albumin) or a combination of protein and carbohydrate (egg albumin and sucrose or glucose) were later developed to create a semi-starvation state with success.
  • However, in the late 1970s, liquid milk formula-based diets began to be produced from low-quality protein (hydrolysed collagen or gelatine) that was nutrient incomplete and led to 60 deaths in the USA.
  • The deaths were later attributed to cardiac complications resulting from a starvation response from prolonged and extremely rapid weight loss (~30% body weight in 4 months) in otherwise healthy people with obesity.
  • Higher-quality protein and more nutritionally complete VLEDs are now used and clinical trials from the early 1980s ‘til now, show that VLEDs are a safe and highly effective weight loss intervention for the management of obesity.
  • In Australia, most VLED’s provide < 3,350 kJ (800 Calories) a day.
  • “Shakes”, bars, or soups.
  • Generally consumed 3 x day.
Food-based VLED
An example food-based 3,350 kJ (800 Calories) per day meal plan:
  • 1/3 Cup oats
  • 2/3 Cup milk
Morning tea
  • Tea/coffee
  • ½ small can salmon or tuna
  • 1 cup salad vegetables
Afternoon tea
  • Tea/coffee
  • 90g lean beef/chicken strips
  • 1/3 Cup noodles
  • 1 ½ Cup stir fry vegetables
  • 1 teaspoon oil
  • 2/3 Cup plain yoghurt
  • 1 small piece fruit
Low Energy (kilojoule/calorie) Diets

What are the consequences?

  Both overweight and obesity are associated with the incidence of multiple health problems, including, but not limited to:
  • cardiovascular diseases (e.g., heart disease and stroke)
  • cancers (e.g., colorectal)
  • osteoarthritis
  • gallbladder disease
  • pre-diabetes and type 2 diabetes (collectively: impaired glucose metabolism)

Overweight, obesity and impaired glucose metabolism

Diabetes: progression or remission?
  • recently, type 2 diabetes was considered to be a progressive condition.
  • Following the path:
    normal glucose tolerance → pre-diabetes → type 2 diabetes.
  • Disease management has primarily focused on delaying progression rather than achieving remission.
SOURCE: Kelly et al. American Journal of Lifestyle Medicine. 2020; Steven et al. Diabet. Med. 2013
  • Publication of evidence about the reversibility of type 2 diabetes in the UK in 2011 was followed by over 1000 enquiries from people with diabetes.
  • The overwhelming sentiment expressed was profound relief at the possibility that the condition was not inevitably permanent.
  • Prevention/remission will reduce treatment costs and the additional burden of disease due to macro and microvascular complications.
  • Diabetes reversal should be a goal in the management of type 2 diabetes.
Reduced Energy Diets
  • Tailor-made to the individual.
  • Generally recommend that people need to consume ~2,300 kJ less each day to lose 0.5 kg/week.
  • Based on evidence-based diabetes guidelines and dietary guidelines for the general population (when specific advice for people with diabetes or pre-diabetes is unavailable).
Efficacy of VLEDs versus other diets
  • On average, VLEDs produce 1.2 kg – 3.2 kg weight loss per week in the acute phase in approximately 80% of individuals and are a more effective long-term mode of weight loss than a food-based energy-reduced intervention.
  • A recent systematic review and meta-analysis of 5 clinical trials where participants consumed VLEDs over 4 – 52 weeks determined that total weight loss ranged from 8.9 to 15 kg in those with type 2 diabetes and 7.9 to 21 kg in those without diabetes.
  • There is a 3.1-fold greater likelihood of losing 10% clinically significant weight loss at 24 months after a four-month meal replacement diet of 65 to 75% energy restriction (followed by moderate energy restriction for 8 months), compared to a 12 month 25–35% moderate energy-reduced food-based diet.