Effectiveness of a Total Meal Replacement Program (OPTIFAST Program) on Weight Loss: Results from the OPTIWIN Study

Meal replacements on obesity and leptin: a systematic review and meta-analysis

The global prevalence of obesity and overweight is a significant concern in the field of public health. Numerous interventional studies have been conducted to assess the possible meal replacements (MRs) effect on anthropometric indicators and indices and laboratory test that reflect obesity. However, there are no comprehensive results in this field. The study aim was to understand the possible effects of MRs on body weight, body mass index (BMI), fat mass, waist circumferences (WC), and leptin levels. A systematic search was conducted in five electronic databases in order to find randomized clinical trials (RCTs) that examined the possible MRs effect on obesity. Analyses were performed in R software, version 4.2.1. The random-effects model analysis was used to provide pooled mean difference and 95% confidence intervals (95% CI). Seventy studies were included. Body weight (WMD: -3.35 kg, 95% CI: -4.28 to -2.42), BMI (WMD: -1.12 kg/m2, 95% CI: -1.51 to -0.72), fat mass (WMD: -2.77 kg, 95% CI: -3.59 to -1.6), WC (WMD: -2.82 cm, 95% CI: -3.51 to -2.12) were significantly reduced after MRs compared to control. No significant effect was observed on leptin (WMD: -3.37 ng/ml, 95% CI: -8.23 to 1.49). Subgroup analyses indicated that impact of total MRs on anthropometric factors was greater in comparison to partial MRs. Considering other lifestyle factors, MRs can lead to anthropometric indicators and indices reduction.

Meal replacement therapy for obesity and diabetes remission: efficacy assessment and considerations of barriers and facilitators to adherence among U.S. individuals with low economic resources

Individuals in the United States with lower economic resources face a disproportionate burden of obesity and co-morbid conditions. This review summarizes the efficacy of MR programs for the treatment of obesity and diabetes and alerts clinicians to potential barriers and facilitators to the uptake of such programs so they may tailor their prescriptive approach. Implementation of effective behavioral and lifestyle interventions for obesity and diabetes in low-income settings is fraught with barriers and under-studied. The dearth of data on the use of MR programs in populations with low economic resources highlights a key area for future investigation.

Nutritional considerations with antiobesity medications

The improved efficacy and generally favorable safety profile of recently approved and emerging antiobesity medications (AOMs), which result in an average weight reduction of ≥15%, represent significant advancement in the treatment of obesity. This narrative review aims to provide practical evidence-based recommendations for nutritional assessment, management, and monitoring of patients treated with AOMs. Prior to treatment, clinicians can identify preexisting nutritional risk factors and counsel their patients on recommended intakes of protein, dietary fiber, micronutrients, and fluids. During treatment with AOMs, ongoing monitoring can facilitate early recognition and management of gastrointestinal symptoms or inadequate nutrient or fluid intake. Attention should also be paid to other factors that can impact response to treatment and quality of life, such as physical activity and social and emotional health. In the context of treatment with AOMs, clinicians can play an active role in supporting their patients with obesity to improve their health and well-being and promote optimal nutritional and medical outcomes.

The NHS Low-Calorie Diet Digital Programme: Fidelity of behaviour change technique delivery

AIMS

NHS England commissioned independent service providers to deliver the NHS Low-Calorie Diet Programme pilot. Previous research has illustrated a drift in the fidelity of behaviour change techniques (BCTs) during the delivery of the programme provided through face-to-face group or one-to-one behavioural support. The aim of this study was to assess the delivery fidelity of the BCT content in the digital delivery of the programme.

METHODS

Online, app chat and phone call support content was coded using The Behaviour Change Technique Taxonomy. BCTs delivered by each service provider (N = 2) were calculated and compared to the BCTs specified in the NHS service specification and those specified in the providers' programme plans.

RESULTS

Between 78% and 83% of the BCTs identified in the NHS service specification were delivered by the service providers. The fidelity of BCT delivery to those specified in providers' programme plans was 60%-65% for provider A, and 82% for provider B.

CONCLUSIONS

The BCT content of the digital model used in the NHS-LCD programme adhered well to the NHS service specification and providers' plans. It surpassed what has been previously observed in face-to-face services provided through group or one-on-one behavioural support models.

The latest evidence and clinical guidelines for use of meal replacements in very-low-calorie diets or low-calorie diets for the treatment of obesity

Obesity is a complex chronic disease with increasing prevalence across the globe. Medical nutrition therapy (MNT) is an important component of obesity treatment, and low-calorie diets (LCDs) and very-low-calorie diets (VLCDs) are part of the MNT toolbox. This narrative review focuses on the latest evidence and clinical guidelines regarding the use and impact of meal replacements (MRs) as part of LCDs/VLCDs for the treatment of obesity and some associated complications. MRs can be used in conjunction with food as partial diet replacement (PDR) or can be used exclusively to serve as the sole source of dietary energy (total diet replacement [TDR]). Use of MR may be associated with better control of cravings and hunger typically observed during reduced calorie intake through effects of ketosis or stimuli narrowing, although the exact mechanisms for these effects remain unclear. Several clinical guidelines have endorsed the use of MRs as a part of MNT for obesity, primarily based on evidence that shows an average weight reduction of ~10 kg or more with TDR over at least 12 months in large, randomized controlled trials. When compared to usual care controls, these effects are 6-8 kg greater, and when compared to food-based diets, the effects are nearly twice the effect of a food-based diet. MR-based diets have been found to be safe and associated with improvements in quality of life. These diets are also effective for improving key cardiometabolic health outcomes, including dysglycaemia, blood pressure, lipids, and metabolic associated fatty liver. The effectiveness, safety, and associated health improvement makes MRs use a valuable strategy for several higher risk clinical scenarios where weight reduction is indicated.

Effects of Very Low-Calorie Diet versus Roux-en-Y Gastric Bypass Surgery on Body Composition in Patients with Obesity

Roux-en-Y gastric bypass (RYGB) is the most effective treatment for severe obesity. A very low-calorie diet (VLCD) is another effective dietary intervention to treat obesity. This study evaluated the effect of a VLCD versus RYGB on weight reduction, changes in body composition and the resolution of comorbidities during a 12-week period. Individuals with obesity at the obesity clinic, Ramathibodi Hospital, Mahidol University, Thailand with a body mass index (BMI) ≥ 37.5 kg/m2 or ≥32.5 kg/m2 with obesity-related complications were recruited. Treatment options, either RYGB or VLCD, were assigned depending on patients' preferences and physicians' judgment. The analysis included 16 participants in the RYGB group and 15 participants in the VLCD group. Baseline characteristics were similar between groups; nevertheless, the participants in the VLCD group were significantly younger than those in the RYGB group. The number of patients with type 2 diabetes (T2D) was slightly higher in the RYGB group (43.8% vs. 33.3%, p = 0.552). Additionally, patients in the RYGB group had a longer duration of T2D and were treated with anti-diabetic agents, while VLCD patients received only lifestyle modifications. At 12 weeks, total and percentage weight loss in the RYGB and VLCD groups, respectively, were as follows: -17.6 ± 6.0 kg vs. -15.6 ± 5.1 kg (p = 0.335) and -16.2% ± 4.3% vs. -14.1% ± 3.6% (p = 0.147). Changes in biochemical data and the resolution of comorbidities were similar between the groups at 12 weeks. A 12-week VLCD resulted in similar weight loss and metabolic improvement compared with RYGB. Large-scale studies with long follow-up periods are needed to elucidate whether VLCD is a viable alternative treatment to bariatric surgery.

A low-calorie meal replacement improves body composition and metabolic parameters in shift workers with overweight and obesity: a randomized, controlled, parallel group trial

BACKGROUND

Shift work has been identified as a risk factor for several chronic health conditions including obesity. This study evaluated the impact of a low-calorie meal replacement (MR) as a dinner substitute on body composition and metabolic parameters in shift workers with overweight and obesity.

METHODS

An 8-week parallel, randomized controlled trial was conducted on overweight and obese shift workers in a large hospital. An intervention group (IG) (n = 25) was provided with a low-calorie MR shake (∼200 kcal) as a replacement for dinner, every day for 8 weeks, while the control group (CG) (n = 25) continued their habitual diet. Anthropometric measurements, body composition, biochemical, and lifestyle data were assessed at the first and last visits. Analyses were done per protocol (PP) and by intention to treat (ITT).

RESULTS

Over the study duration, both groups displayed moderate changes in anthropometric measurements and body composition, although these were not statistically significant according to the PP analysis. In the ITT analysis, apart from the hip circumference (HC), all other anthropometric parameters demonstrated significant group and time interactions, suggesting the advantageous effects of the meal replacement over the study period (P < 0.05). HDL and VLDL cholesterol measures showed significant main effects, influenced by both group (P = 0.031) and time (P = 0.050) respectively. The most pronounced dietary shift in the IG was a reduction in carbohydrate consumption and an increase in protein intake. Throughout the study, the meal replacement was well-tolerated, with no adverse events reported.

CONCLUSIONS

The meal replacement dietary intervention appears to offer beneficial health effects over time. Extended research is crucial to understand the broader implications of meal replacements across diverse populations.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12622000231741. Registered on 09 February 2022. https://www.anzctr.org.au/ACTRN12622000231741.aspx .

Successful dietary changes correlate with weight-loss outcomes in a new dietary weight-loss program

Background

Currently available behavioral and dietary weight-loss programs lack magnitude and sustainability compared with bariatric surgery. A novel dietary weight-loss program was developed to assist participants in achieving sustainable diet changes by building knowledge and skills in food self-selection. Although the approach worked, a large variation was observed in outcome among participants.

Objective

Determine factors affecting weight-loss outcomes among participants to further improve the efficacy of the program.

Methods

Participants attended 19 dietary educational sessions during a 1-year intervention which included prescribed homework. Changes in weight, diet, and body composition were assessed.

Results

Participants (n = 22) achieved mean body weight loss of -6.49(8.37%, p < 0.001) from baseline at 12 months. Nine participants (41%) achieved weight loss >5% of initial bodyweight; two reached a Body Mass Index 25 kg/m2. A large divergence in weight loss among participants was observed; successful (n = 9) achieved -12.9(9.6)% while unsuccessful achieved -2.03(2.78)%. Dietary protein and fiber density by 24-h records showed a significant and inverse correlation with weight loss (%) throughout the program. Weight loss at 3 months and 12 months showed a strong correlation (r = 0.84). Participants with self-reported depression lost significantly less weight than those without depression at 12 months (p < 0.03).

Conclusions

Divergence in weight-loss outcomes among the participants is likely due to a difference in successful dietary implementation. Intra-cohort analysis indicates early weight-loss success and early dietary implementation was predictive of long-term success.

PReoperative very low-Energy diets for obese PAtients undergoing non-bariatric surgery Randomized Evaluation (PREPARE): a protocol for a pilot randomized controlled trial

BACKGROUND

Patients with obesity presenting in need of surgical intervention are at 2-to-sixfold higher risk of prolonged hospitalization, infectious morbidity, venous thromboembolism, and more. To mitigate some of these concerns, prescribed preoperative weight loss via very low-energy diets (VLEDs) has become a standard of care for patients with obesity undergoing bariatric surgery. While VLEDs have become standard prior to bariatric surgery, their application in other surgical settings remains limited. A large, definitive trial is required to resolve the uncertainty surrounding their use in these patients. Prior to a definitive trial to compare the efficacy of VLEDs in patients with obesity undergoing major non-bariatric surgery, we require a pilot trial. We argue a pilot trial will provide the following critical feasibility insights: (1) assessment of recruitment ability, (2) evaluation of adherence to VLED regimens, and (3) assessment of our ability follow patients completely.

METHODS

The proposed trial will be a multi-center, surgeon, outcome assessor, and data-analyst blinded, parallel pilot randomized controlled trial (RCT). Patients older than 18 years of age with a body mass index (BMI) of greater than 30 kg/m2 undergoing major elective non-bariatric surgery will be eligible for inclusion. Consecutive patients will be allocated 1:1 according to a computer-generated randomization schedule. Randomization will be stratified by center and will employ randomly permutated blocks. All patients in the intervention group will receive standard patient counseling on weight loss and an active VLED protocol. The preoperative VLED protocol will utilize commercially available weight loss products for three weeks preoperatively. The primary outcomes (randomization percentage, recruitment rate, intervention adherence, follow-up completion, network development) will assess feasibility. Descriptive statistics will be used to characterize the study sample.

DISCUSSION

The PREPARE pilot RCT will aim to provide feasibility and safety data that will allow for the successful completion of the definitive PREPARE trial that has the potential to provide practice changing data pertaining to the regular use of VLEDs as a means of pre-habilitation for patients with obesity undergoing major non-bariatric surgery.

TRIAL REGISTRATION

This study was registered on ClinicalTrials.gov (reference #NCT05918471) on June 23, 2023.

PREscribing preoperative weight loss prior to major non-bariatric abdominal surgery for patients with Elevated weight: Patient and Provider Survey Protocols (PREPARE surveys)

BACKGROUND

Preoperative very low energy diet (VLED) interventions are used routinely in patients undergoing bariatric surgery, a surgical subspecialty that deals almost exclusively with patients with obesity. Yet, their use and study has been limited in non-bariatric abdominal surgery. To investigate the use of VLEDs in non-bariatric surgery, we plan on conducting a randomized controlled trial (RCT). Prior to proceeding, however, we have designed two surveys as important pre-emptive studies aimed at elucidating patient and provider perspectives regarding these interventions.

METHODS

The patient survey is a cross-sectional, single-center survey aimed at assessing the safety, adherence, barriers to adherence, and willingness to participate in preoperative optimization protocols with VLEDs prior to undergoing elective non-bariatric intra-abdominal surgery (S1 File). The population of interest is all adult patients with obesity undergoing elective non-bariatric intra-abdominal surgery at St. Joseph's Healthcare Hamilton who were prescribed a course of preoperative VLED. The primary outcomes will be safety and adherence. The target sample size is 35 survey responses. The provider survey is a cross-sectional national survey of practicing surgeons in Canada who perform major non-bariatric abdominal surgery aimed assessing the willingness and ability to prescribe preoperative weight loss interventions amongst practicing Canadian surgeons who perform major non-bariatric abdominal surgery (S2 File). The population of interest is independent practicing surgeons in Canada who perform major non-bariatric abdominal surgery. The primary outcome will be willingness to prescribe preoperative VLED to patients with obesity undergoing major non-bariatric abdominal surgery for both benign and malignant indications. The target sample size is 61 survey responses. Descriptive statistics will be used to characterize the sample populations. To determine variables associated with primary outcomes in the surveys, regression analyses will be performed.

DISCUSSION

These survey data will ultimately inform the design of an RCT evaluating the efficacy of preoperative VLEDs for patients with obesity undergoing major abdominal surgery.

Effects of Additional Protein Intake on Lean Body Mass in Patients Undergoing Multimodal Treatment for Morbid Obesity

(1) Multimodal treatment is a standard treatment for patients with obesity. However, weight loss also leads to reductions in fat-free mass. The aim was to investigate whether additional protein intake contributes to better preservation of lean body mass (LBM). (2) A total of 267 obesity patients (age 45.8 years; BMI 47.3 kg/m2) were included in this analysis. For the first 12 weeks of the program, patients were given a formula-based diet of 800-1000 kcal per day. Patients were divided into a control group (CG) (n = 148) and a protein group (PG) (n = 119). The PG was characterized by an additional protein intake with the aim of consuming 1.5 g of protein per kilogram of normalized body weight, whereas the CG had a protein intake of 1 g/kg/d. Bioelectrical impedance analysis was performed at the beginning (t0) and after 12 weeks (t1) of the program. (3) There were no significant differences between the groups with respect to weight loss (p = 0.571). LBM was also significantly reduced in both groups, without significant differences between CG and PG. (4) Increased protein intake had no significant effect on body composition of morbidly obese patients during a 12-week formula-based diet and multimodal treatment.

The OPTIFAST total and partial meal replacement programme reduces cardiometabolic risk in adults with obesity: Secondary and exploratory analysis of the OPTIWIN study

AIM

The effects of weight loss with a partial or total meal replacement programme (MRP) on atherosclerotic cardiovascular disease (ASCVD) risk factors are not fully understood, in particular in people at higher CV risk. In the 52-week randomized controlled OPTIWIN study in men and women with obesity, meal replacement programme (total for first 26 weeks, partial for the ensuing 26 weeks) with OPTIFAST (OP) resulted in significantly greater weight loss compared with a low-calorie food-based (FB) dietary plan, both as part of a comprehensive lifestyle intervention [OP (n = 135)/FB (n = 138) week 26: -12.4%/-6.0%, p < .001; week 52: -10.5%/-5.5%, p < .001]. Here, we examined effects on ASCVD risk factors and 10-year ASCVD risk.

MATERIALS AND METHODS

Participants with body mass index 30-55 kg/m2 and age 18-70 years, and not on anti-obesity medications, were recruited. The effects on systolic and diastolic blood pressure (SBP, DBP), lipid parameters and 10-year ASCVD risk were analysed as changes over time using linear mixed models. Subgroup analyses were conducted for changes in SBP, DBP and ASCVD risk by categories of age (<40, 40-59, ≥60 years), baseline SBP (

RESULTS

Baseline characteristics were well balanced (OP/FB females 86%/79%, mean age 47/47 years, body mass index 38.4/39.2 kg/m2 , 10-year ASCVD risk <5% 87%/74%, dysglycaemia 52%/50%). At week 26, SBP/DBP were significantly reduced with OP versus FB, and a greater proportion achieved BP ≤130/80 mmHg [odds ratio 2.11 (95% confidence interval 1.10, 4.03), p = .024]. All lipid parameters as well as 10-year ASCVD risk were significantly improved with OP versus FB. A similar, but slightly attenuated pattern was observed at 52 weeks. Across subgroups, greater reductions for SBP, DBP and ASCVD risk were generally seen with OP versus FB with quantitatively higher baseline SBP and age, and in men.

CONCLUSIONS

In people with obesity at low ASCVD risk, OP significantly reduced cardiovascular risk factors and 10-year predicted risk for ASCVD.

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Key Words

• blood pressure
• body weight
• caloric restriction
• clinical trial
• heart disease risk factors
• obesity management

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MESH Headings

• Adult
• Male
• Humans
• Female
• Middle Aged
• Adolescent
• Young Adult
• Aged
• Obesity/complications
• Obesity/epidemiology
• Blood Pressure
• Risk Factors
• Weight Loss
• Atherosclerosis
• Lipids
• Hypertension/drug therapy

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Grants

• Nestlé Health Science

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Affiliation(s)

Jamy D Ard Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
Ian J Neeland Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
Amy E Rothberg University of Michigan, Ann Arbor, Michigan, USA
Robert J Chilton University of Texas Health Science Center, San Antonio, Texas, USA
Daniel de Luis Center of Investigation of Endocrinlogy and Nutrition, University of Valladolid, Hospital clínico Universitario de Valladolid, Valladolid, Spain
Sarah S Cohen EpidStrategies, A Division of Tox Strategies Inc., Katy, Texas, USA
Odd Erik Johansen Nestlé Health Science, Lausanne, Switzerland

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Weight regain after total meal replacement very low-calorie diet program with and with-out anti-obesity medications

Background

Very low-calorie diets (VLCDs) employing total meal replacement (TMR) offer substantial short-term weight loss. Concurrently, anti-obesity medications (AOMs) have shown promise as adjunctive treatments when combined with VLCDs.

Aims

This study aimed to investigate the impact of adjuvant AOMs on weight loss and weight regain within a comprehensive lifestyle program.

Methods

This is a retrospective study of patients with obesity enrolled in VLCD/TMR programs,  specifically the OPTIFAST program.

Results

Data from 206 patients (68% women, mean age 52.39 ± 13.05 years, BMI 41.71 ± 7.04 kg/m2) were analyzed. Of these, 139 received no AOM (AOM-), while 67 received AOMs (AOM+). Total body weight loss percentages (TWL%) at 6 and 18 months were -17.87% ± 7.02 and -12.10% ± 11.56, respectively. There was no significant difference in 6-month weight loss between the AOM groups. However, the AOM + group exhibited lower weight regain (3.29 kg ± 10.19 vs. 7.61 kg ± 11.96; p = 0.006) and weight regain percentage (WR%) (31.5% ± 68.7 vs. 52.16% ± 64.4; p = 0.04) compared with the AOM- group.

Conclusion

The findings highlighted the potential of AOMs and VLCD/TMR as effective strategies for long-term weight management in individuals with obesity.

A comparison of virtual and in person delivery of a full meal replacement program for obesity

Objective

Full meal replacement (FMR) Intensive Lifestyle Interventions (ILI) have been used for weight management. However, predictors of efficacy with these programs are less clear. The primary objective was to assess weight loss predictors in a community-based FMR ILI program. A secondary objective was to determine if weight loss was different between virtual and in person ILI.

Methods

This was a retrospective cohort study involving 234 patients who started the program between 1 January 2016 and 3 March 2021. In the 24-week program, patients spent 12 weeks on FMR and then transitioned back to food for the remainder, with weekly follow up with a physician and group sessions with a dietitian. Visits were in person prior to March 2020 and virtual afterward.

Results

Patients' average age was 47.5 years (SD = 12.0) and 73.5% were female. Average weight loss was 14.3% (SD = 6.2%). There was no significant difference in weight loss between virtual and in person programs. Patients on a Glucagon-like Peptide-1 Receptor Agonist prior lost less weight. Other significant associations between groups were baseline Hemoglobin A1C, classes attended, as well as the age since peak weight.

Conclusion

Weight loss from virtual ILI was not significantly different from person ILI. More research is needed to determine how to best stratify care as virtual or in person using FMR programs.

Real world evidence on the characteristics of regular and intermittent users of a very-low calorie diet program and associations with measures of program success, health, and quality of life

Background

Very low-calorie diet (VLCD) programs are readily available in Australia. However, there is a lack of real-world evidence describing the characteristics related to positive outcomes.

Aims

To examine the demographic, eating, self-efficacy and program engagement characteristics of VLCD users in Australia, and the associations between user characteristics and program success, weight loss, quality of life (QOL) and health.

Method

Cross-sectional data from Australian adults: regular users (n = 189: VLCD user ≥4 days/week for >4 weeks) and intermittent users (n = 111, VLCD user <4 weeks and/or <4 days/week). Self-reported data on demographics, VLCD program use, support, eating behavior, weight-related QOL, mental health, physical health, self-efficacy, and physical activity. Descriptive and inferential statistics were performed in R.

Results

Compared to regular users, intermittent users reported lower percentage weight loss (15.1% ± SD 9.8 vs. 9.9% ± SD 6.8, relative to starting weight), fewer reported their VLCD program as very successful (44% vs. 35%), higher depressive symptom scores (8.7 ± SD 2.8 vs. 6.7 ± SD 5.1), and lower general self-efficacy (23.9 ± SD 4.7 vs. 29.4 ± SD 5.7), nutrition self-efficacy (11.9 ± SD 2.0 vs. 14.5 ± SD 3.1) and weight-related QOL scores (60.9 ± SD 22.2 vs. 65.0 ± SD 11.8; p < 0.001 for all). In regular users, older age and longer program duration were associated with greater total weight loss, support, and program success (p < 0.001 for all). In intermittent users, program success was greater when dietitian support was used (odds ratio [OR] 6.50) and for those with higher BMIs (OR 1.08, p < 0.001 for all). In both groups, more frequent support was associated with better weight-related QOL (p < 0.001).

Conclusion

This study provides real-world evidence that regular VLCD users had greater success and weight loss than intermittent program users. These findings may be used to tailor and improve the delivery of VLCD programs in Australia and other countries with retail access to VLCDs.

Normalisation and equity of referral to the NHS Low Calorie Diet programme pilot; a qualitative evaluation of the experiences of health care staff

BACKGROUND

Health and wellbeing can be profoundly impacted by both obesity and type 2 diabetes, while the normalisation and equity of care for people living with these non-communicable diseases remain as challenges for local health systems. The National Health Service Low Calorie Diet programme in England, aims to support people to achieve type 2 diabetes remission, while also reducing health inequalities. We have explored the experiences of health care staff who have made a referral to the LCD programme, while identifying effective and equitable delivery of programme referrals, and their normalisation into routine care.

METHODS

Nineteen individual semi-structured interviews were completed health care staff in the first year of the Low Calorie Diet programme. Interviewees were purposively sampled from the ten localities who undertook the Low Calorie Diet programme pilot. Each interview explored a number of topics of interest including communication and training, referrals, equity, and demands on primary care, before being subjected to a thematic analysis.

RESULTS

From the data, five core themes were identified: Covid-19 and the demands on primary care, the expertise and knowledge of referrers, patient identification and the referral process, barriers to referrals and who gets referred to the NHS LCD programme. Our findings demonstrate the variation in the real world settings of a national diabetes programme. It highlights the challenge of COVID-19 for health care staff, whereby the increased workload of referrals occurred at a time when capacity was curtailed. We have also identified several barriers to referral and have shown that referrals had not yet been normalised into routine care at the point of data collection. We also raise issues of equity in the referral process, as not all eligible people are informed about the programme.

CONCLUSIONS

Referral generation had not yet been consistently normalised into routine care, yet our findings suggest that the LCD programme runs the risk of normalising an inequitable referral process. Inequalities remain a significant challenge, and the adoption of an equitable referral process, normalised at a service delivery level, has the capacity to contribute to the improvement of health inequalities.

Commercial provider staff experiences of the NHS low calorie diet programme pilot: a qualitative exploration of key barriers and facilitators

BACKGROUND

The National Health Service Type 2 Diabetes Path to Remission programme in England (known as the NHS Low Calorie Diet programme when piloted) was established to support people living with excess weight and Type 2 Diabetes to lose weight and improve their glycaemic control. A mixed method evaluation was commissioned to provide an enhanced understanding of the long-term cost effectiveness of the pilot programme, its implementation, equity and transferability across broad and diverse populations. This study provided key insights on implementation and equity from the service providers' perspective.

METHODS

Thirteen focus groups were conducted with commercial providers of the programme, during the initial pilot rollout. Participants were purposively sampled across all provider organisations and staff roles involved in implementing and delivering the programme. Normalisation Process Theory (NPT) was used to design the topic schedule, with the addition of topics on equity and person-centredness. Data were thematically analysed using NPT constructs with additional inductively created codes. Codes were summarised, and analytical themes generated.

RESULTS

The programme was found to fulfil the requirements for normalisation from the providers' perspective. However, barriers were identified in engaging GP practices and receiving sufficient referrals, as well as supporting service users through challenges to remain compliant. There was variation in communication and training between provider sites. Areas for learning and improvement included adapting systems and processes and closing the gap where needs of service users are not fully met.

CONCLUSIONS

The evaluation of the pilot programme demonstrated that it was workable when supported by effective primary care engagement, comprehensive training, and effective internal and external communication. However, limitations were identified in relation to programme specifications e.g. eligibility criteria, service specification and local commissioning decisions e.g. pattern of roll out, incentivisation of general practice. A person-centred approach to care is fundamental and should include cultural adaptation(s), and the assessment and signposting to additional support and services where required.

Effects of gastric bypass bariatric surgery on gut microbiota in patients with morbid obesity

The Western diet is associated with gastrointestinal dysbiosis, an active contributor to the pathophysiology of obesity and its comorbidities. Gastrointestinal dysbiosis is strongly linked to increased adiposity, low-grade inflammation, dyslipidaemia, and insulin resistance in individuals with morbid obesity. Bariatric bypass surgery remains the most effective treatment for achieving significant weight loss and alleviating obesity-related comorbidities. A growing body of evidence indicates that traditional Roux-en-Y Gastric Bypass (RYGB) improves the disrupted gut microbiota linked with obesity, potentially contributing to sustained weight loss and reduction of comorbidities. One Anastomosis Gastric Bypass (OAGB), a relatively new and technically simpler bariatric procedure, has shown both safety and efficacy in promoting weight loss and improving comorbidities. Few studies have investigated the impact of OAGB on gut microbiota. This review provides insights into the pathogenesis of obesity, current treatment strategies and our current understanding of the gut microbiota in health and disease, including modulating the gut microbiota as a promising and novel way to alleviate the burden of obesity and cardiometabolic conditions. By exploring the impact of gastric bypass surgery on gut microbiota-host interactions, we aim to shed light on this evolving field of research and uncover potential therapeutic targets for elevating outcomes in bariatric surgery.

A history of bariatric surgery before surgery for colorectal cancer may improve short-term postoperative outcomes: Analysis of the national inpatient sample 2015-2019

BACKGROUND

Bariatric surgery is the most effective and sustainable form of weight loss. Bariatric surgery before elective operations for colorectal pathology may improve postoperative outcomes. To compare patients with and without prior bariatric surgery undergoing surgery for colorectal cancer in terms of postoperative morbidity and health care use.

METHODS

Adult patients undergoing resection for colorectal cancer from 2015 to 2019 were identified from the National Inpatient Sample. Patients were stratified according to their history of bariatric surgery. Propensity score matching with 4:1 nearest-neighbor matching was performed according to demographic, operative, and hospital characteristics. The primary outcome was postoperative morbidity. Secondary outcomes included system-specific postoperative complications, postoperative mortality, postoperative length of stay, total admission health care cost, and post-discharge disposition. McNemar's test and Wilcoxon matched-pairs signed-rank test were performed.

RESULTS

After propensity score matching, 1,197 patients without prior bariatric surgery and 376 patients with prior bariatric surgery were included. Patients with prior bariatric surgery had an absolute reduction of 6.5% in overall in-hospital postoperative morbidity (19.1% vs 25.6%, P < .0001), a $5,256 decrease in hospitalization cost ($70,344 vs $75,600, P = .034), and were more likely to be discharged home after their index operation (72.9% vs 63.9%, P < .0001).

CONCLUSION

Bariatric surgery before surgery for colorectal cancer may be associated with decreased postoperative morbidity and health care use. Bariatric surgery and other forms of rapid and effective weight loss, such as very low-energy diets, should be evaluated further for the optimization of obese patients before nonbariatric abdominal surgery.

Effects of weight loss and weight loss maintenance on cardiac autonomic function in obesity: a randomized controlled trial

NOVELTY

Caloric restriction and exercise exert significant improvements in cardiac autonomic function as measured by HRV in overweight and obesity. Aerobic exercise training, within recommended guidelines coupled with weight loss maintenance, retains cardiac autonomic function benefits from weight loss in previously obese individuals.

Efficacy and Safety of Intragastric Balloon Therapy Compared to a Multidisciplinary Weight Loss Program (OPTIFAST) in a Real-World Population: A Propensity Score Matching Analysis

INTRODUCTION

Obesity is a major global health problem associated with comorbidities such as diabetes, cardiovascular disease, and cancer. Bariatric surgery is recognized to be the most effective weight loss intervention, but it is highly invasive and costly and can have serious side effects. Intragastric balloon (IGB) placement by endoscopy and hypocaloric diets are among a number of techniques that have been used in patients unsuitable for, or unwilling to undergo, obesity surgery. In this study, we compared the efficacy, safety, and cost-effectiveness of the hypocaloric OPTIFAST program (OPT) with endoscopic IGB placement for weight loss.

METHODS

In this retrospective observational cohort propensity score-weighted comparison (performed May 2014 to December 2020), participants with a BMI of 30-55 kg/m2, aged 18-70 years, were randomized to OPT or IGB for 26 weeks, followed by a weight maintenance phase. Patients were matched according to age, gender, and BMI. The study outcomes were percentage excess body weight lost, total body weight lost (TBWL), and percentage TBWL (%TBWL).

RESULTS

A total of 148 participants (75% of those randomized; 74 OPT, 74 IGB) made up the ITT population. Mean age was 44.1 ± 10.4 years, and the patients were predominantly female (77%). Baseline BMI was 44.1 ± 10.4 kg/m2. At 26 weeks, %TBWL in the OPT group was 19.6 ± 6.8% versus 11.9 ± 6.7% for IGB (p < 0.001). At 52 weeks, %TBWL for OPT was 18.2 ± 9.0% versus 12.0 ± 6.6% for IGB (p < 0.001). The OPT cohort also experienced significantly fewer adverse events compared with the IGB group.

CONCLUSION

IGB placement and OPT induce clinically meaningful weight loss. However, OPT appears to induce clinically superior weight loss and has economic advantages through lower rates of complications and adverse events.

Kosten-Effektivitäts-Analyse des Optifast 52 Programms bei Patienten mit Adipositas Grad III und Diabetes mellitus Typ 2

Hintergrund Adipositas stellt für eine Vielzahl weiterer Erkrankungen einen wesentlichen Risikofaktor dar, darunter insbesondere Diabetes mellitus Typ 2 (DMT2). DMT2 als Adipositas-assoziierte Folgeerkrankung bedeutet sowohl aus medizinischer als auch ökonomischer Sicht eine hohe Belastung für das deutsche Gesundheitssystem. Ziel therapeutischer Maßnahmen zur Gewichtsreduktion bei Patienten mit DMT2 ist somit immer auch die Verbesserung der diabetischen Stoffwechsellage. Bei Patienten mit Adipositas Grad III (BMI≥40 kg/m2) kann alternativ zu einer metabolischen bariatrischen Operation auch ein strukturiertes, multimodales Therapieprogramm (Optifast 52 Programm) angeboten werden.

Methodik In einer Kosten-Effektivitäts-Analyse sollen die gesundheitsökonomischen Auswirkungen des Optifast 52 Programms im Vergleich zur metabolischen Operation bei adipösen Patienten (BMI 40–50 kg/m2) mit DMT2 als Adipositasassoziierter Begleiterkrankung ermittelt werden. Ziel beider Therapieoptionen ist die Remission des DMT2 aufgrund von Gewichtsreduktion. Mithilfe eines Entscheidungsbaum-Modells wird die Therapie des DMT2 für einen Zeitraum von drei Jahren modelliert. Berücksichtigt werden die direkten medizinischen Kosten aus Perspektive der gesetzlichen Krankenversicherung in Deutschland.

Ergebnisse Die kumulierten Behandlungskosten des DMT2 liegen unter Anwendung des Optifast 52 Programms bei durchschnittlich 9.425,01 Euro für den Gesamtzeitraum von drei Jahren im Vergleich zu 13.727,94 Euro für Patienten mit metabolischer Operation. Unter Berücksichtigung der Effektivität der beiden Therapieoptionen zeigt sich, dass das Optifast 52 Programm mit 11.536,33 Euro im Vergleich zu 14.908,56 Euro für eine metabolische Operation kosteneffektiv ist.

Schlussfolgerung Die Reduktion des Körpergewichts ist bei Patienten mit Adipositas wesentlich für eine erfolgreiche Therapie des DMT2. Die metabolische Operation kann dabei zu deutlichen Gewichtsverlusten führen, ist jedoch aufgrund der vergleichsweise höheren Komplikationsraten und der hohen finanziellen Belastung für das deutsche Gesundheitssystem kritisch zu sehen. Aus gesundheitsökonomischer Sicht stellt das Optifast 52 Programm deswegen eine kosteneffektive Alternative zur metabolischen Operation dar.

Effects of an Intermittent Fasting 5:2 Plus Program on Body Weight in Chinese Adults with Overweight or Obesity: A Pilot Study

To retrospectively review the efficacy of intermittent fasting 5:2 plus program (30% of energy requirements on fast days and 70% of energy requirements on nonfasting days) in Chinese patients with overweight or obesity. This retrospective cohort study evaluated weight loss outcomes of patients treated with 12 weeks weight loss program in clinic. Adults with overweight or obesity participated in intermittent fasting 5:2 plus, daily calorie restriction (70% of energy requirements every day) or daily calorie restriction with meal replacement (70% of energy requirements every day, partly provided with high-protein meal replacement) programs for 12 weeks. The primary objective was to compare the weight loss of three groups. The primary outcome measure was the change in the % total weight loss. A total of 131 patients (35.3 ± 10.1 years; 81.7% female) were included, and the mean weight loss was 7.8 ± 4.4% after 12 weeks. The intermittent fasting 5:2 plus group (n = 42) achieved 9.0 ± 5.3% weight loss, compared with 5.7 ± 3.7% in the daily calorie restriction group (n = 41) (p < 0.001) and 8.6 ± 3.5% in the meal replacement group (n = 48) (p = 0.650). A total of 85.7% of patients in the intermittent fasting 5:2 plus group lost more than 5% body weight, vs. 58.5% in the daily calorie restriction group (p = 0.008), and 45.2% lost more than 10% body weight, vs. 14.6% in the daily calorie restriction group (p = 0.005). No serious adverse events were reported in the three groups. The intermittent fasting 5:2 plus program more effectively led to weight loss than daily calorie restriction in the short-term in Chinese patients with overweight or obesity. A longer-term prospective randomized controlled trial is needed.

A feasibility study to test a novel approach to dietary weight loss with a focus on assisting informed decision making in food selection

Obesity is a significant contributor to the development of chronic diseases, some of which can be prevented or reversed by weight loss. However, dietary weight loss programs have shortcomings in the success rate, magnitude, or sustainability of weight loss. The Individualized Diet Improvement Program's (iDip) objective was to test the feasibility of a novel approach that helps individuals self-select a sustainable diet for weight loss and maintenance instead of providing weight loss products or rigid diet instructions to follow. The iDip study consisted of 22 dietary improvement sessions over 12 months with six months of follow-up. Daily weights were collected, and a chart summarizing progress was provided weekly. Six 24-hour dietary records were collected, and dietary feedback was provided in the form of a protein-fiber plot, in which protein/energy and fiber/energy of foods were plotted two-dimensionally together with a target box specific to weight loss or maintenance. An exit survey was conducted at 12 months. Twelve (nine female, 46.3±3.1 years (mean±SE)) of the initial 14 participants (BMI>28 kg/m2) completed all sessions. Mean percent weight loss (n = 12) at six and 12 months was -4.9%±1.1 (p = 0.001) and -5.4%±1.7 (p = 0.007), respectively. Weight loss varied among individuals at 12 months; top and bottom halves (n = 6 each) achieved -9.7%±1.7 (p = 0.0008) and -1.0%±1.4 weight loss, respectively. The 24-hour records showed a significant increase in protein density from baseline to final (4.1g/100kcal±0.3 vs. 5.7g/100kcal±0.5; p = 0.008). Although mean fiber density showed no significant change from the first month (1.3g/100kcal±0.1), the top half had significantly higher fiber/energy intake than the bottom half group. The survey suggested that all participants valued the program and its self-guided diet approach. In conclusion, half of the participants successfully lost >5% and maintained the lost weight for 12 months without strict diet instructions, showing the feasibility of the informed decision-making approach.

Changes in the Leptin to Adiponectin Ratio Are Proportional to Weight Loss After Meal Replacement in Adults With Severe Obesity

Hypocaloric diets are known to induce changes in adipokine secretion, but the influence of a low energy liquid diet (LELD) on the leptin: adiponectin ratio (LAR), a measure of insulin resistance and cardiovascular risk, has not previously been investigated in patients with severe obesity. We conducted a prospective, single-center cohort study of adults with severe obesity (defined as body mass index (BMI) ≥40 kgm−2, or ≥35 kgm−2 with co-morbidities) who completed a 24-week milk-based LELD. We measured leptin, adiponectin and LAR at the start and on completion of the programme. Of 120 patients who started, 52 (43.3 %) completed the programme. Their mean age was 50.3 ± 11.2 (range 18–74) years, 29 (55.8 %) were female and 20 (38.5 %) had type 2 diabetes mellitus (T2DM). Weight decreased from 148.2 ± 39.6 to 125.4 ± 34.8 kg and BMI decreased from 52.4 ± 11.1 to 44.3 ± 9.8 kgm−2, respectively (all p &lt; 0.001). In patients with T2DM, HbA1c decreased from 60.0 ± 17.4 to 47.5 ± 15.5 mmol/mol (p &lt; 0.001). Leptin decreased (from 87.2 [48.6, 132.7] to 39.1 [21.0, 76.4] ng/ml) and adiponectin increased (from 5.6 [4.5, 7.5] to 7.1 [5.5, 8.5] μg/ml), with a reduction in LAR from 15 [8.4, 22.4] to 5.7 [3.0, 9.1] ng/μg (all p &lt; 0.001), indicating decreased insulin resistance. The percentage weight lost was associated with the percentage reduction in LAR (ß = 2.9 [1.7, 4.1], p &lt; 0.001) and this association was stronger in patients with T2DM. Patients with severe obesity who completed a milk-based LELD had a substantial reduction in LAR, consistent with decreased insulin resistance and cardiovascular risk, proportional to weight loss.

Nutrition Concepts for the Treatment of Obesity in Adults

Obesity caused by a positive energy balance is a serious health burden. Studies have shown that obesity is the major risk factor for many diseases like type 2 diabetes mellitus, coronary heart diseases, or various types of cancer. Therefore, the prevention and treatment of increased body weight are key. Different evidence-based treatment approaches considering weight history, body mass index (BMI) category, and co-morbidities are available: lifestyle intervention, formula diet, drugs, and bariatric surgery. For all treatment approaches, behaviour change techniques, reduction in energy intake, and increasing energy expenditure are required. Self-monitoring of diet and physical activity provides an effective behaviour change technique for weight management. Digital tools increase engagement rates for self-monitoring and have the potential to improve weight management. The objective of this narrative review is to summarize current available treatment approaches for obesity, to provide a selective overview of nutrition trends, and to give a scientific viewpoint for various nutrition concepts for weight loss.

A high-protein total diet replacement alters the regulation of food intake and energy homeostasis in healthy, normal-weight adults

PURPOSE

Dietary intake can affect energy homeostasis and influence body weight control. The aim of this study was to compare the impact of high-protein total diet replacement (HP-TDR) versus a control (CON) diet in the regulation of food intake and energy homeostasis in healthy, normal-weight adults.

METHODS

In this acute randomized controlled, cross-over study, participants completed two isocaloric arms: a) HP-TDR: 35% carbohydrate, 40% protein, and 25% fat; b) CON: 55% carbohydrate, 15% protein, and 30% fat. The diets were provided for 32 h while inside a whole-body calorimetry unit. Appetite sensations, appetite-related hormones, and energy metabolism were assessed.

RESULTS

Forty-three healthy, normal-weight adults (19 females) participated. Appetite sensations did not differ between diets (all p > 0.05). Compared to the CON diet, the change in fasting blood markers during the HP-TDR intervention was smaller for peptide tyrosine-tyrosine (PYY; - 18.9 ± 7.9 pg/mL, p = 0.02) and greater for leptin (1859 ± 652 pg/mL, p = 0.007). Moreover, postprandial levels of glucagon-like peptide 1 (1.62 ± 0.36 pM, p < 0.001) and PYY (31.37 ± 8.05 pg/mL, p < 0.001) were higher in the HP-TDR. Significant correlations were observed between energy balance and satiety (r = - 0.41, p = 0.007), and energy balance and PFC (r = 0.33, p = 0.033) in the HP-TDR.

CONCLUSION

Compared to the CON diet, the HP-TDR increased blood levels of anorexigenic hormones. Moreover, females and males responded differently to the intervention in terms of appetite sensations and appetite-related hormones.

TRIAL REGISTRATION

NCT02811276 (retrospectively registered on 16 June 2016) and NCT03565510 (retrospectively registered on 11 June 2018).

Five Years of MBSAQIP Data: Characteristics, Outcomes, and Trends for Patients with Super-obesity

PURPOSE

Incidence of super obesity (SO; BMI ≥ 50 kg/m²) is growing rapidly and confers worse metabolic complications than non-SO (BMI 30-50 kg/m²). We aim to characterize bariatric surgery patients with SO, their postoperative complications, and treatment trends over the last 5 years in hopes of informing SO-specific treatment protocols.

MATERIALS AND METHODS

The MBSAQIP database was analyzed, and two cohorts were compared, those with SO and non-SO. Univariate analysis was performed to determine between-group differences. Multivariable logistic regression analysis was performed to determine if SO was independently associated with serious complications or mortality.

RESULTS

We evaluated 751,952 patients with 173,110 (23.0%) having SO. Patients with SO were younger (42.2 ± 11.8 SO vs 45.1 ± 12.0 years non-SO, p < 0.001) and less likely to be female (74.8% vs 81.1%, p < 0.001). While comorbidities seem to be decreasing overall in bariatric surgery patients, those with SO have worse functional capacity and more endocrine, pulmonary, and vascular comorbidities. Patients with SO also have worse 30-day postoperative complications, and SO was independently associated with severe complications (OR 1.08; CI 1.05-1.11, p < 0.001) and mortality (OR 2.49; CI 2.12-2.92, p < 0.001) CONCLUSIONS: Patients with SO have significantly increased preoperative comorbidities resulting in worse postoperative outcomes. SO remains an independent risk factor for serious complications and the greatest independent risk factor for 30-day postoperative mortality. Considering the expected increase in patients with SO, substantial work is required to optimize bariatric surgery strategies specific to these patients.

Adult obesity management in New Zealand general practice: a review

INTRODUCTION Obesity is an important issue that leads to further health complications, increases the strain on the national health system and lowers quality of life. There is little available information on obesity management to guide best practice in general practice, despite 32% of New Zealand adults reported to be obese. AIM To review obesity management in New Zealand general practice. METHODS We searched six online databases for peer-reviewed research about adult obesity management. Inclusion criteria were original research, a New Zealand adult sample aged 25-64 years with a body mass index (BMI) >30 (or >25 BMI if participants had comorbidities) with weight loss (kg) as a measurable outcome. RESULTS Eleven articles were identified: nine studies reported statistically significant weight loss from baseline, and two studies reported no significant weight loss. Three studies used a Kaupapa Māori approach. Weight loss results ranged from 0.56 to 12.1 kg. Weight loss interventions varied in strategy and suitability for individual patients. DISCUSSION We found that there are effective weight loss interventions available for primary health-care professionals to refer to. Although most interventions did produce some weight loss, patients may need more comprehensive interventions that include a combination of diet, exercise and behaviour modifications in culturally appropriate ways. Future research should aim to identify and mitigate potential barriers to obesity management in primary care, as well as develop comprehensive, multileveled interventions that are effective for the local population.

The BAriatic surgery SUbstitution and nutrition (BASUN) population: a data-driven exploration of predictors for obesity

BACKGROUND

The development of obesity is most likely due to a combination of biological and environmental factors some of which might still be unidentified. We used a machine learning technique to examine the relative importance of more than 100 clinical variables as predictors for BMI.

METHODS

BASUN is a prospective non-randomized cohort study of 971 individuals that received medical or surgical treatment (treatment choice was based on patient's preferences and clinical criteria, not randomization) for obesity in the Västra Götaland county in Sweden between 2015 and 2017 with planned follow-up for 10 years. This study includes demographic data, BMI, blood tests, and questionnaires before obesity treatment that cover three main areas: gastrointestinal symptoms and eating habits, physical activity and quality of life, and psychological health. We used random forest, with conditional variable importance, to study the relative importance of roughly 100 predictors of BMI, covering 15 domains. We quantified the predictive value of each individual predictor, as well as each domain.

RESULTS

The participants received medical (n = 382) or surgical treatment for obesity (Roux-en-Y gastric bypass, n = 388; sleeve gastrectomy, n = 201). There were minor differences between these groups before treatment with regard to anthropometrics, laboratory measures and results from questionnaires. The 10 individual variables with the strongest predictive value, in order of decreasing strength, were country of birth, marital status, sex, calcium levels, age, levels of TSH and HbA1c, AUDIT score, BE tendencies according to QEWPR, and TG levels. The strongest domains predicting BMI were: Socioeconomic status, Demographics, Biomarkers (notably TSH), Lifestyle/habits, Biomarkers for cardiovascular disease and diabetes, and Potential anxiety and depression.

CONCLUSIONS

Lifestyle, habits, age, sex and socioeconomic status are some of the strongest predictors for BMI levels. Potential anxiety and / or depression and other characteristics captured using questionnaires have strong predictive value. These results confirm previously suggested associations and advocate prospective studies to examine the value of better characterization of patients eligible for obesity treatment, and consequently to evaluate the treatment effects in groups of patients.

TRIAL REGISTRATION

March 03, 2015; NCT03152617 .

Extended follow-up of a short total diet replacement programme: results of the Doctor Referral of Overweight People to Low Energy total diet replacement Treatment (DROPLET) randomised controlled trial at 3 years

Objectives

To test the long-term effectiveness of a total diet replacement programme (TDR) for routine treatment of obesity in a primary care setting.

Methods

This study was a pragmatic, two-arm, parallel-group, open-label, individually randomised controlled trial in adults with obesity. The outcomes were change in weight and biomarkers of diabetes and cardiovascular disease risk from baseline to 3 years, analysed as intention-to-treat with mixed effects models.

Interventions

The intervention was TDR for 8 weeks, followed by food-reintroduction over 4 weeks. Behavioural support was provided weekly for 8 weeks, bi-weekly for the next 4 weeks, then monthly for 3 months after which no further support was provided. The usual care (UC) group received dietary advice and behavioural support from a practice nurse for up to 3 months.

Results

Outcome measures were collected from 179 (66%) participants. Compared with baseline, at 3 years the TDR group lost −6.2 kg (SD 9.1) and usual care −2.7 kg (SD 7.7); adjusted mean difference −3.3 kg (95% CI: −5.2, −1.5), p < 0.0001. Regain from programme end (6 months) to 3 years was greater in TDR group +8.9 kg (SD 9.4) than UC + 1.2, (SD 9.1); adjusted mean difference +6.9 kg (95% CI 4.2, 9.5) P < 0.001. At 3 years TDR led to greater reductions than UC in diastolic blood pressure (mean difference −3.3 mmHg (95% CI:−6.2; −0.4) P = 0.024), and systolic blood pressure (mean differences −3.7 mmHg (95% CI: −7.4; 0.1) P = 0.057). There was no evidence of differences between groups in the change from baseline to 3 years HbA_1c (−1.9 mmol/mol (95% CI: −0.7; 4.5; P = 0.15), LDL cholesterol concentrations (0.2 mmol/L (95% CI −0.3, 0.7) P = 0.39), cardiovascular risk score (QRISK2) (−0.37 (95% CI −0.96; 0.22); P = 0.22).

Conclusions

Treatment of people with obesity with a TDR programme compared with support from a practice nurse leads to greater weight loss which persists to at least 3 years, but there was only evidence of sustained improvements in BP and not in other aspects of cardiometabolic risk.

The Effect of Meal Replacement on Weight Loss According to Calorie-Restriction Type and Proportion of Energy Intake: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Portion control is a useful component of weight reduction interventions and meal replacement (MR) plans represent a promising strategy for portion control. Research performed with pooled data on the effect of MR plans according to various characteristics of MR interventions remains scarce.

OBJECTIVE

Our aim was to assess the effects of MR-based diets compared with food-based diets on weight loss, according to calorie-restriction types and energy intake proportions from MR.

METHODS

Electronic databases (Cochrane Central Register of Controlled Trials, PubMed, Embase, and Research Information Sharing Service) were searched for randomized controlled trials on weight loss results of MR-based calorie-restricted diets compared with food-based calorie-restricted diets from January 2000 to May 2020. Standardized mean differences (Hedges' g) from all study outcomes were calculated using a random-effects model. Heterogeneity was quantified by Q test and I². Publication bias was assessed using a funnel plot and a trim and fill method. Both interventions (MR and control) were separated into very-low-energy diets and low-energy diets (LEDs). A meta-analysis of variance was conducted by dividing patient-related factors and treatment-related factors into subgroups. In multivariable meta-regressions, background variables were selected first, after which main independent variables were included.

RESULTS

Twenty-two studies involving 24 interventions and 1,982 patients who were overweight or obese were included. The effect size in which MR-based LED was compared with food-based LED for weight loss was small, favoring MR (Hedges' g = 0.261; 95% CI 0.156 to 0.365; I² = 21.9; 95% CI 0.0 to 53.6). Diets including ≥60% of total daily energy intake from MR had a medium effect size favoring MR with regard to weight loss among the groups (Hedges' g = 0.545; 95% CI 0.260 to 0.830; I² = 42.7; 95% CI 0.0 to 80.8).

CONCLUSIONS

The effect of MR-based LED on weight loss was superior to the effect of food-based LED, and receiving ≥60% of total daily energy intake from MR had the greatest effect on weight loss.

Commercial Weight Loss Programs in the Management of Obesity: an Update

PURPOSE OF REVIEW

Comprehensive lifestyle programs are cornerstones of obesity management, but clinician referrals may be limited by program availability. Commercial weight loss programs may be an alternative, but clinicians may be unaware of their efficacy and safety. This review describes the evidence for commercial programs, particularly 12-month weight loss, among individuals with obesity.

RECENT FINDINGS

Several programs are concordant with evidence-based recommendations (i.e., lower-calorie diet, increased physical activity, and behavioral strategies). Among the guideline-concordant programs, National Diabetes Prevention Program, WW, Jenny Craig, Medifast, and OPTIFAST have demonstrated 12-month weight loss efficacy and safety. While other programs show promise, more evidence is needed before clinician referral may be recommended. Clinical practice guidelines support referrals to commercial weight loss programs that have peer-reviewed evidence to support their efficacy and safety. Clinicians should consider the available evidence, patient preference, and cost when considering referrals to these programs for weight management.

Intermittent and continuous energy restriction result in similar weight loss, weight loss maintenance, and body composition changes in a 6 month randomized pilot study

Poor adherence is a barrier to successful weight control. Intermittent energy restriction (IER) provides an alternative approach to those for whom daily energy restriction is not ideal. This study assessed changes in weight, body composition, and macronutrient intake for an IER and a continuous energy restriction (CONT) approach within a multicomponent weight management intervention. We randomized 35 adults with overweight/obesity (BMI = 31.2 ± 2.4 kg/m² ) to CONT or IER for 24 weeks (12-week weight loss intervention and 12 weeks of weight loss maintenance). Diets were delivered within a multimodal weight management program including weekly group meetings with a registered dietitian, increased physical activity, and a comprehensive lifestyle change program. Retention and adherence were similar for CONT and IER. Weight, BMI, fat mass, percentage body fat, waist circumference, hip circumference, blood pressure, and heart rate all decreased after 24 weeks (all, P < .01), but there were no main effects of group (all, P > .27). Weight loss was clinically relevant in both CONT (11.38 ± 7.9%) and IER (9.37 ± 9.7%), and the proportion of each group achieving 5% weight loss was 82 and 61% (P = .16), respectively. Participant satisfaction was high in both groups. The results from this study (a) support the feasibility of IER as an alternative for weight loss and weight loss maintenance, (b) indicate that IER is an effective alternative to CONT for weight control and improvements in body composition, and (c) emphasize the importance of intensive lifestyle interventions with ongoing support for effective behaviour modification.

Health-Related Quality of Life in Weight Loss Interventions: Results from the OPTIWIN Trial

Obesity is highly prevalent and associated with several adverse outcomes including health-related quality-of-life (HRQoL), work productivity, and activity impairment. The objective of this study is to examine group differences in HRQoL and labor-related health outcomes among participants in the OPTIWIN program, which compared the effectiveness of two intensive behavioral weight loss interventions. Participants (n = 273) were randomized to OPTIFAST^®(OP) or food-based (FB) dietary interventions for 52 weeks. HRQoL and labor-related health outcomes were measured at baseline, week 26, and week 52, using two questionnaires. At baseline, there were no differences between groups on the Impact of Weight on Quality-of-Life Questionnaire (IWQOL-Lite). At week 26, the OP group had statistically significant differences towards better HRQoL for Physical Function, Self-Esteem, and the total score compared with the FB group. At week 52, the OP group showed better HRQoL in the total score (p = 0.0012) and in all but one domain. Moreover, the adjusted change-from-baseline normalized total score at week 52 was −5.9 points (p = 0.0001). Finally, the mean IWQOL-Lite normalized score showed that HRQoL improves by 0.4442 units (p < 0.0001) per kg lost, and that greater weight reduction was positively associated with better HRQoL. No statistically significant group differences were found with the Work Productivity and Activity Impairment (General Health) (WPAI-GH) Questionnaire. HRQoL improves with highly intensive, well-structured weight loss interventions. Greater weight loss lead to larger improvements. The lack of negative effect on productivity and activity suggests that these interventions may be compatible with an active work lifestyle.

A high-protein total diet replacement increases energy expenditure and leads to negative fat balance in healthy, normal-weight adults

BACKGROUND

High-protein diets and total diet replacements are becoming increasingly popular for weight loss; however, further research is needed to elucidate their impact on the mechanisms involved in weight regulation.

OBJECTIVE

The aim of this inpatient metabolic balance study was to compare the impact of a high-protein total diet replacement (HP-TDR) versus a control diet (CON) on select components of energy metabolism in healthy adults of both sexes.

METHODS

The acute intervention was a randomized, controlled, crossover design with participants allocated to 2 isocaloric arms: 1) HP-TDR: 35% carbohydrate, 40% protein, and 25% fat achieved through a nutritional supplement; 2) CON: 55% carbohydrate, 15% protein, and 30% fat. Participants received the prescribed diets for 32 h while inside a whole-body calorimetry unit (WBCU). The first dietary intervention randomly offered in the WBCU was designed to maintain energy balance and the second matched what was offered during the first stay. Energy expenditure, macronutrient oxidation rates and balances, and metabolic blood markers were assessed. Body composition was measured at baseline using DXA.

RESULTS

Forty-three healthy, normal-weight adults (19 females and 24 males) were included. Compared with the CON diet, the HP-TDR produced higher total energy expenditure [(EE) 81 ± 82 kcal/d, P <0.001], protein and fat oxidation rates (38 ± 34 g/d, P <0.001; 8 ± 20 g/d, P = 0.013, respectively), and a lower carbohydrate oxidation rate (-38 ± 43 g/d, P <0.001). Moreover, a HP-TDR led to decreased energy (-112 ± 85 kcal/d; P <0.001), fat (-22 ± 20 g/d; P <0.001), and carbohydrate balances (-69 ± 44 g/d; P <0.001), and increased protein balance (90 ± 32 g/d; P <0.001).

CONCLUSIONS

Our primary findings were that a HP-TDR led to higher total EE, increased fat oxidation, and negative fat balance. These results suggest that a HP-TDR may promote fat loss compared with a conventional isocaloric diet. These trials were registered at clinicaltrials.gov as NCT02811276 and NCT03565510.

Dynamics of hepatic steatosis resolution and changes in gut microbiome with weight loss in nonalcoholic fatty liver disease

Background

Weight loss is recommended as the primary treatment for nonalcoholic fatty liver disease (NAFLD). However, the magnitude and velocity of hepatic steatosis resolution with weight loss is unclear, making it difficult to counsel patients seeking weight loss for treatment of NAFLD. The aim of this study was to determine the rate of hepatic steatosis improvement and stool microbiome changes associated with rapid diet‐induced weight loss in NAFLD.

Methods

Fourteen NAFLD patients (mean ± standard deviation, body mass index [BMI] 36.4 ± 4 kg/m²) enrolled in a 12‐week meal replacement program underwent frequent measurement of Fibroscan‐controlled attenuation parameter (CAP). Magnetic resonance imaging (MRI‐Dixon method) for hepatic fat quantitation and stool microbiome analysis (16S rRNA gene sequencing) were completed in 11 subjects at baseline and Week 12.

Results

At Week 12, mean (95% confidence interval) weight loss was −13.4 (−15.2, −11.5)% and CAP score −26.6 (−35.6, −17.6)% (both Ps < 0.001). CAP scores changed at a rate of −4.9 dB/m/kg (−30.1 dB/m per unit BMI) in Weeks 1–4 and −0.6 dB/m/kg (−2.4 dB/m per unit BMI) in Weeks 8–12. MRI‐determined hepatic fat fraction decreased by −74.1% (p < 0.001) at a rate of −0.51%/kg (−3.19% per unit BMI), with complete steatosis resolution in 90% patients. BMI change was associated with decreased stool microbial diversity (coefficient = 0.17; Shannon Index), increased abundance of Prevotella_9 (Bacteroidetes; coefficient = 0.96) and decreased abundance of Phascolarctobacterium (Firmicutes; coefficient = −0.42) (both Ps < 0.05).

Conclusions

Diet‐induced intensive weight loss is associated with rapid improvement and complete resolution of hepatic steatosis and decreased stool microbial diversity. These findings highlight the dynamic nature of hepatic fat and may help clinicians to develop evidence‐based treatment goals for patients with NAFLD and obesity who undertake weight loss interventions. Further research is warranted to understand the effects of intensive weight loss and gut microbiome changes on long‐term NAFLD resolution.

Differences in treatment response to a total diet replacement intervention versus a food-based intervention: A secondary analysis of the OPTIWIN trial

OBJECTIVE

For every weight loss treatment, there are usually groups of people who lose less than expected. This study sought to determine if response rates to a total diet replacement (TDR) differed from those of a calorie-restricted, food-based (FB) diet.

METHODS

Data from OPTIWIN, a 12-month multicenter trial in adults with a BMI of 30-55 kg/m2, with 26-week weight-loss and weight-maintenance phases, were utilized. Participants (n = 330) were randomized to the OPTIFAST programme (OP) or to a reduced-energy FB diet. Treatment non-responders were defined as those who lost <3% of initial weight at months 6 or 12.

RESULTS

There were 103 (76%) responders in the OP compared with 78 (57%) in the FB group at 12 months. The odds of treatment response at 12 months among participants who were non-responders at 3 months was not significantly different between the OP and FB groups (p = 0.64). Race, type 2 diabetes status and previous weight loss attempts were significantly associated with responder status. OP responders had higher meal plan adherence and non-caloric fluid intake compared with FB responders.

CONCLUSION

Early treatment response is more likely and better sustained with TDR compared with an FB diet. Individual and treatment level factors appear to influence early treatment response to behavioural interventions for weight reduction.

Nocturnal eating but not binge eating disorder is related to less 12 months' weight loss in men and women with severe obesity: A retrospective cohort study

There is a paucity of studies on the frequency of binge-eating disorder (BED) and nocturnal eating (NE) and their potential role as barriers in non-surgical weight loss treatment in subjects with severe obesity (body mass index [BMI] ≥35 kg m² ). The aim was to identify BED and NE, and their effect on weight loss treatment. In total, 1132 (727 women, 405 men), BMI ~41 kg/m² were patients in a 12-month weight loss programme at a specialist clinic. The questionnaire for eating and weight patterns-revised was completed by the patients before start of treatment. BED was diagnosed in 5.1% of men and 12.4% of women. NE prevalence was 13.5% and 12.7%, respectively. Mean (±SEM) 12-month weight loss was less in patients with NE compared to those without (-11.0 ± 1.5 vs -14.6 ± 0.7 kg, P = .008) but did not differ in patients with and without BED, (-12.3 ± 1.9 vs -14.2 ± 0.6 kg, P = .24). Factors associated with dropout were BED (odds ratio, OR 1.57, 95% confidence interval (CI) 1.14-2.17; P = .006) and previous weight loss attempts (OR 1.35, 95% CI 1.0-1.7; P = .02). BED did not seem to hinder weight loss whereas NE resulted in less weight loss in patients with severe obesity who completed a 12-month treatment programme. Previous weight loss attempts affect both dropout and ability to lose weight.

Weight loss is associated with sustained improvement of disease activity and cardiovascular risk factors in patients with psoriatic arthritis and obesity: a prospective intervention study with two years of follow-up

Background

Obesity is overrepresented in patients with psoriatic arthritis (PsA) and associated with increased disease activity. We have previously shown in 41 patients with PsA (Caspar criteria) and obesity (body mass index; BMI ≥33 kg/m²) that weight loss treatment with Very Low Energy Liquid Diet (VLED), 640 kcal/day during 12–16 weeks, followed by a structured reintroduction of an energy restricted diet resulted in a median weight loss of 18.6% and concomitantly a significant improvement of the disease activity in joints, entheses and skin.

The objectives of this follow-up were to study the effects of the weight loss treatment on disease activity in longer term (12 and 24 months) and to study the effects on cardiovascular risk factors.

Methods

The patients were assessed with 66/68 joints count, Leeds enthesitis index (LEI), body surface area, blood pressure, BMI, questionnaires and fasting blood samples at the 12- and 24-month visits.

Results

In total, 39 and 35 PsA patients attended the 12- and the 24-month visits, respectively. Median weight loss since baseline was 16.0% (IQR 10.5–22.4) and 7.4% (IQR 5.1–14.0) at the 12- and 24-months follow-up. The 66/68 swollen/tender joints score, LEI, CRP and HAQ score were still significantly reduced at the 12- and 24-month visits compared to baseline. The number of patients with Minimal Disease Activity increased from 28.2% (11/39) at baseline, to 38.5% (15/39; p = 0.008) and 45.7% (16/35; p = 0.016) at the 12- and 24-month visits.

The weight loss was also associated with improved levels of serum lipids, glucose and urate and the antihypertensive treatment was reduced or stopped in five patients during the follow-up.

Conclusions

Weight loss treatment, with VLED included in the program, was associated with long-term improvement of measures of disease activity, self-reported function and markers of the metabolic syndrome after 24-months follow-up.

Trial registration

ClinicalTrials.gov identifier: NCT02917434, Registered September 28, 2016- Retrospectively registered.

Participant experiences of a low-energy total diet replacement programme: A descriptive qualitative study

Introduction

The participants’ experience of low-energy total diet replacement (TDR) programmes delivered by lay counsellors in the community for the routine treatment of obesity is currently unclear. We interviewed a sample of twelve participants who took part in the Doctor Referral of Overweight People to Low-Energy total diet replacement Treatment (DROPLET) trial and were randomised to the TDR programme.

Methods

We purposively sampled twelve patients who took part in the DROPLET trial, and conducted in-depth telephone interviews, which were audio-recorded and transcribed verbatim. Interview questions focused on participants’ experiences and perceptions of the TDR programme. We conducted a thematic analysis, actively developing themes from the data, and used the one sheet of paper (OSOP) technique to develop higher-level concepts.

Results

Nine key themes were identified; Reasons for taking part, Expectations, Support and guidance from the counsellor, Time to build a personal relationship, Following the TDR Programme, Adverse events, Outcomes from the TDR, Weight Loss Maintenance, Recommending TDR to others. The relationship between participants and the counsellor was central to many of the themes. Close relationships with counsellors facilitated TDR adherence through providing one-to-one support (including during difficult times), sharing expert knowledge, and building a close relationship. Adherence was also supported by the rapid weight loss that patients reported experiencing. Overall participants reported positive experiences of the TDR, and emphasised the positive impact on their wellbeing.

Discussion

Patients reported that a TDR programme delivered by lay counsellors in the community was a positive experience and effective in helping them to lose weight. Future trials should consider the central role of the person providing support and advice as a key component in the programme.

Barriers to and Facilitators of Weight Management in Adults Using a Meal Replacement Program That Includes Health Coaching

Purpose: The Academy of Nutrition and Dietetics supports meal replacement (MR) programs as an effective diet-related weight management strategy. While MR programs have been successful promoting initial weight loss, weight regain has been as high as 50% 1 year following MR program participation. The purpose of this article is to identify barriers to and facilitators of weight loss (WL) and weight loss maintenance (WM) among individuals participating in a MR program. Methods: Sixty-one MR program clients participated in focus groups (WL = 29, WM = 32). Barriers and facilitators were discussed until saturation of themes was reached. Focus group transcriptions were coded into themes to identify the barriers to and facilitators of weight management that emerged within each phase. Queries were run to assess frequencies of references to each theme. Results: The primary barriers within the WL phase included program products, physical activity, and social settings. WM phase participants referenced nutrition, lack of health coach knowledge, and physical activity as barriers. Personal benfits, ability to adhere to the program, and family support emerged as leading facilitators for WL phase participants. Personal benefits, health coach support, and physical activity emerged as facilitators by WM phase participants. Conclusions: Health coaches have the unique opportunity to use perceived facilitators to improve participant success, and help participants address their personal barriers in order to progress through successful, long-term weight management. Current health coaching models used in MRP should aim to identify participants’ specific barriers and develop steps to overcome them.

Role of Commercial Weight-Loss Programs in Medical Management of Obesity

Rates of obesity counseling are low among physicians because of the lack of time and training in this area. In recognition of this challenge, recent national guidelines encourage physicians to refer patients with obesity to intensive, comprehensive lifestyle programs to lose weight. Some commercial weight-loss programs meet these criteria, and this article reviews the evidence from randomized controlled trials regarding such programs' weight-loss efficacy and safety as well as glycemic outcomes among patients with and without diabetes mellitus. A discussion of how physicians might approach the referral process and continued management of patients participating in these programs is included.

Mineral profile of weight loss related foods marketed in Spain

Low calorie foods are products designed to replace complete meals or to control snacking in many hypocaloric diets. These products provide many nutrients to the human diet, but little is known about their mineral elements composition. Here we study the mineral profile of weight loss related products, including the analysis of 22 elements (As, Ba, Be, Bi, Cd, Co, Cr, Cu, K, Mn, Mo, Na, Ni, P, Pb, Th, Tl, Sb, U, V, Y and Zn) in 73 commercial products marketed in Spain. In general a portion of these products provide up to 20-30% of the daily dietary reference intake of essential trace minerals like Cr or Mo. On the contrary, some of these foods have large concentrations of toxic minerals like As, Cd or Pb. In fact, the intake of those products with higher concentrations of toxic elements during a weight loss program could pose a risk to human health.

Effects of Exercise during Weight Loss Maintenance on Appetite Regulation in Women

Exercise is accepted as a method to improve weight loss maintenance; however, the mechanisms by which this occurs have yet to be elucidated. In this pilot study, 13 women with obesity underwent a structured weight loss program (goal 8%-10% weight loss) and were then randomized to either a 12-wk diet (n = 7) or an aerobic exercise training (n = 6) intervention aimed at maintaining weight loss. At baseline, post-weight loss, and following the weight loss maintenance interventions, measurements of appetite (hunger and satiety) and appetite-regulating hormones (leptin, ghrelin, peptide tyrosine tyrosine, and glucagon-like peptide 1) were obtained after an overnight fast and for 3 h after a standardized test meal. Ad libitum energy intake was measured at a lunch meal. During the weight loss phase, participants lost 9.1% ± 1.1% of baseline body weight. Participants in both groups maintained weight loss during the 12-wk weight loss maintenance intervention. No differences in fasting leptin (P = 0.68) or in ghrelin (P = 0.30), peptide tyrosine tyrosine (P = 0.93), and glucagon-like peptide 1 (P = 0.98) area under the curve were detected between groups. Similarly, ratings of hunger (P = 0.99) and satiety (P = 0.65) area under the curve after the standardized test meal also did not differ between the groups nor did ad libitum energy intake at lunch. In summary, the 12-wk diet and exercise interventions were equally effective at maintaining weight loss in women, and no differences in measures of appetite regulation and food intake were found.

Dietary modifications for weight loss and weight loss maintenance

Worldwide obesity rates remain at a rise, and to treat obesity is at the top of the global public health agenda. In 2013, the AHA/ACC/TOS obesity management guidelines were published, in essence suggesting that any dietary scheme seems to be effective for weight loss, as long as it can induce a sustainable energy deficit. In the present review, we update and critically discuss available information regarding dietary modifications for weight loss and weight loss maintenance, published after the 2013 guidelines. Regarding weight loss, we found no proof to support that a single dietary scheme, be it nutrient-, food group- or dietary pattern- based, is more efficacious of the other for achieving weight loss. For weight loss maintenance, published interventions point towards the same direction, although inconclusively. Most research explores the effect of weight loss regimes on weight loss maintenance and not the effect of the diet during weight loss maintenance, and this literature gap should be more thoroughly investigated.