Liquid meal replacements and glycemic control in obese type 2 diabetes patients

Efficacy and Safety of Meal Replacement in Patients With Type 2 Diabetes

CONTEXT

Meal replacement (MR) is beneficial for the management of type 2 diabetes (T2D). However, MR prescription and patient characteristics vary substantially between studies using MR in T2D patients.

OBJECTIVE

This work aimed to evaluate the efficacy and safety of MR in T2D patients by meta-analysis, with a focus on subgroup analysis of variable participant characteristics and MR prescription.

METHODS

We searched PubMed, CENTRAL, Embase, Web of Science, and the clinical trial registration database up to March 2022. We included randomized controlled trials (RCTs) of 2 weeks or more assessing the effect and safety of MR in T2D patients in comparison with conventional diabetic diets (CDs).

RESULTS

A total of 17 RCTs involving 2112 participants were ultimately included. Compared with CDs, MR significantly reduced glycated hemoglobin A1c (HbA1c) (MD -0.46%; P < .001), fasting blood glucose (FBG, -0.62 mmol/L; P < .001), body weight (-2.43 kg; P < .001), and body mass index (BMI, -0.65; P < .001), and improved other cardiometabolic risk factors. In subgroup analyses, total MR showed greater improvement in HbA1c (-0.72% vs -0.32%; P = .01), FBG (-1.45 vs -0.56 mmol/L; P = .02), body weight (-6.57 vs -1.58 kg; P < .001), and BMI (-2.78 vs -0.37; P < .001) than partial MR. MR with caloric restriction showed more reduction in body weight (-3.20 vs -0.75 kg; P < .001) and BMI (-0.84 vs -0.24; P = .003) compared with those without caloric restriction. MR showed similar benefits in studies that included patients using insulin and those that did not. Both partial and total MR were well tolerated.

CONCLUSION

Compared with CDs, the MR-based dietary pattern further improved the glycemic control and adipose indicators in T2D patients. Appropriate calorie restriction and total MR might be more beneficial, while both patients treated with or without insulin treatment could similarly benefit from MR usage.

Randomized clinical trial to evaluate the effect on postprandial glycemia of Nutren Control®, a glycemia-targeted specialized supplement, compared to standardized breakfast in patients with type-2 diabetes: the CONTROL DIABETES study

Introduction

Objective: to evaluate the effects of a new glycemia targeted specialized supplement (GTSS) compared to a standard breakfast on postprandial blood glucose (PPG). Methods: patients with type 2 diabetes (T2D) and suboptimal control (A1C between 6.5 and 8.5 %) in monotherapy with metformin were included to this prospective, randomized, crossover trial. The standardized breakfast was isoenergetic compared to the GTSS, differing on macronutrients distribution. Both interventions were used once a day in the morning, each replacing breakfast for 7 consecutive days (14 days of observation). Intermittent scanning continuous glucose monitoring system (isCGM) determined the difference between the interventions regarding the incremental area under the curve (iAUC) of the PPG (3 hours after intervention), as a primary endpoint; secondary endpoints were the difference between the interventions regarding the glycemic peak, postprandial glucose excursion (PPGE), mean blood glucose (MBG) and time in range (TIR). Results: thirty-one T2D patients with ages between 39 and 69 years-old were enrolled. GTSS group had significantly lower iAUC of the PPG compared to standardized breakfast (33.3 [15.0 to 54.0] vs 46.8 [27.3 to 75.1] mg/dL), while also presenting a significantly lower PPG excursion (26.4 ± 17.2 vs 44.8 ± 24.4 mg/dL). There was no difference between the intervention periods regarding MBG, TIR and hypoglycemic events. Conclusion: The new GTSS, as a meal replacement in the breakfast, produced a 25 % reduction in the iAUC of the PPG, as accessed by isCGM, in comparison with an isocaloric-standardized meal.

Ten-dimensional hyphenation including simulated static gastro-intestinal digestion on the adsorbent surface, planar assays, and bioactivity evaluation for meal replacement products

Meal replacement products are normally consumed in weight-loss interventions and the treatment of obesity and diabetes. Changing lifestyles and eating habits made meal replacement products in the forms of shakes and bars a good alternative as To-go-meals, promoted as balanced in its composition and thus healthier compared to other ready-to-eat meals. This study aimed to evaluate the bioactivity of six differently flavoured powdered meal replacement products. Their analysis was made by a ten-dimensional hyphenation composed of digestion on the adsorbent surface, followed by normal-phase high-performance thin-layer chromatographic separation, multi-imaging, and planar assay application (effect-directed analysis), and then heart-cut elution/transfer of bioactive compound zones to reversed-phase high-performance liquid chromatography, diode array detection, and high-resolution tandem mass spectrometry. The on-surface digestion of saccharides, fats, and proteins through intestinal enzymatic activity revealed new breakdown products. These exhibited bioactivity in their different effect-profiles obtained by the Gram-negative Aliivibrio fischeri bioassay as well as α-/β-glucosidase and acetyl-/butyrylcholinesterease inhibition assays. The main bioactive compounds arising through simulated static pancreatic digestion were saturated and unsaturated free fatty acids. The synthetic sweetener sucralose was not influenced by simulated static intestinal digestion, but showed antimicrobial activity. In the prepared drinking meals with coffee and choco flavour, the acetylcholinesterase-inhibiting methylxanthines caffeine and theobromine were identified as bioactive compounds. Some other bioactive constituents could not be assigned to specific molecules and require further analyses. Although the studied meal replacement products showed health-beneficial properties through antimicrobial properties or inhibition of enzymes involved in the expression of the civilisation diseases, such as diabetes and Alzheimer's disease, plant foods, herbs and spices have been shown to be even richer and more versatile in bioactive compounds.

Impact of Partial Meal Replacement on Glycemic Levels and Body Weight in Indian Patients with Type 2 Diabetes (PRIDE): A Randomized Controlled Study

INTRODUCTION

Partial meal replacement (PMR) offers potential glycemic and weight control benefits in type 2 diabetes mellitus (T2DM) patients. We evaluated the clinical impact of PMR (diabetes-specific nutritional supplement [DSNS]) in overweight/obese Indian patients with T2DM.

METHODS

PRIDE, a 12-week, phase IV, open-label, multicenter study randomized (1:1) newly diagnosed T2DM patients (≤ 1 year) to either DSNS plus standard of care (SOC; diabetes treatment with dietary counseling) group (PMR) or SOC alone group (SOC). The primary endpoint was mean change in glycated hemoglobin (HbA1c) from baseline to week 12. Secondary endpoints were changes in glucose profiles, body weight, waist circumference, lipid profile, and factors impacting quality-of-life (QoL) at week 6 and 12 from baseline. Safety was assessed throughout the study.

RESULTS

Of the 176 patients enrolled, 171 (n = 85 in PMR group; n = 86 in SOC group) were included in the modified intent-to-treat population. The mean reduction in HbA1c at week 12 from baseline in PMR group was significant compared to the SOC group (- 0.59 vs. - 0.21%, p = 0.002). At week 12, the PMR group showed significant reduction in mean body weight (- 2.19 vs. - 0.22 kg; p = 0.001) and waist circumference (- 2.34 vs. - 0.48 cm; p = 0.001) compared to SOC group. Mean fasting plasma glucose and post-prandial glucose significantly reduced from baseline at week 6 and 12 in each group (p < 0.05). No significant change was observed in lipid profile. QoL parameters (treatment adherence, general well-being, and energy fulfilment) in the PMR were significantly better than SOC group (p < 0.05). Patients were satisfied with the taste of DSNS. No serious adverse events were reported.

CONCLUSIONS

DSNS is an encouraging option for PMR strategy, as it significantly improved HbA1c, body weight, waist circumference, and overall well-being among overweight/obese Indian T2DM patients.

TRIAL IDENTIFICATION NO

CTRI/2019/10/021595.

Complete nutrition drink with retrograded starch is low glycemic, and the individual glucose response to the low glycemic complete nutrition drink depends on fasting insulin levels and HOMA-IR in a randomized cross-over control trial

Complete nutrition drinks with a low glycemic index (GI) provide nutritional support and prevent hyperglycaemia. The present study identified GI and factors predicting individual glucose response to a new complete nutrition drink. A randomised cross-over controlled trial was conducted in eighteen healthy volunteers (FPG < 100 mg/dl). Complete nutrition drinks containing retrograded starch, glucose solution and white bread were assigned in a random sequence with 14-day wash-out intervals. Plasma glucose and insulin levels were measured from baseline to 180 min after consuming each food. Results show the adjusted GIs of the drink was 48.2 ± 10.4 and 46.7 ± 12.7 with glucose and white bread as the reference, respectively. While the drink has low GI (<55), the individual glucose responses varied (GI: 7–149). Comparing characters in individual GI < 55 (n = 12) and GI ≥ 55 (n = 6) groups revealed significantly higher baseline insulin in the low GI group (14.86 ± 16.51 μIU/ml v. 4.9 ± 3.4 μIU/ml, P < 0·05). The correlation matrix confirms only two predictive factors for having individual GI <55 were baseline insulin (r = 0·5, P = 0·03) and HOMA-IR (r = 0·55, P = 0·02). ROC curve reveals fasting insulin above 1.6 μIU/ml and HOMA-IR above 1.05 as the cut-off values. The findings suggest that the complete nutrition drink has a low GI, but there was wide variability in individual responses partly explained by fasting insulin levels and HOMA-IR. Screening for fasting insulin and HOMA-IR may be encouraged to maximise the functional benefit of the drink.

Diabetes-Specific Nutrition Formulas in the Management of Patients with Diabetes and Cardiometabolic Risk

Food-based dietary management, enhanced with evidence-based commercial products, such as diabetes-specific nutrition formulas (DSNFs), can help control the development, progression, and severity of certain chronic diseases. In this review, evidence is detailed on the use of DSNFs in patients with or at risk for diabetes and cardiometabolic-based chronic disease. Many DSNF strategies target glycemic excursions and cardiovascular physiology, taking into account various elements of healthy eating patterns. Nevertheless, significant research, knowledge, and practice gaps remain. These gaps are actionable in terms of formulating and testing relevant and pragmatic research questions, developing an educational program for the uniform distribution of information, and collaboratively writing clinical practice guidelines that incorporate the evidence base for DSNF. In sum, the benefits of DNSF as part of validated clinical practice algorithms include mitigation of chronic disease progression, cost-savings for the healthcare system, and applicability on a global scale.

Behaviour change during dietary Type 2 diabetes remission: a longitudinal qualitative evaluation of an intervention using a very low energy diet

AIM

To understand the process of behaviour change through the experiences of people with Type 2 diabetes engaged in an 8-month diabetes remission intervention including a 2-month weight loss phase with the use of a very low energy diet (VLED), and a 6-month, structured weight maintenance phase.

METHODS

Data were collected in three semi-structured interviews at baseline, week 8 (end of the weight loss phase), and month 8 (end of the weight maintenance phase). Longitudinal inductive thematic analysis was used to analyse participants' narratives and identify change over time.

RESULTS

Eleven of 18 participants completed all three interviews. The following themes of change were identified in their narratives: (1) 'Building behavioural autonomy' as a process of growing confidence to engage in health behaviours that are independent of those of other people; (2) 'Behavioural contagion' describing how one's new health behaviours tend to affect those of other people; (3) 'From rigid to flexible restraint', reflecting the changes in attitudes and behaviours required for a successful adaptation from weight loss to weight maintenance; and (4) 'Shift in identity', representing changes in the participants' perceptions of themselves.

CONCLUSIONS

This longitudinal qualitative study provided new insights into how behaviour change is experienced by people with Type 2 diabetes engaged on a weight management intervention using VLED, contributing to theoretical and practical understanding of weight management behaviours. The themes identify potential areas in which individuals can be supported in achieving dietary diabetes remission and long-term maintenance of weight loss.

The Effect of Liquid Meal Replacements on Cardiometabolic Risk Factors in Overweight/Obese Individuals With Type 2 Diabetes: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

The evidence for liquid meal replacements in diabetes has not been summarized. Our objective was to synthesize the evidence of the effect of liquid meal replacements on cardiometabolic risk factors in overweight/obese individuals with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Data sources included MEDLINE, EMBASE, and the Cochrane Library through 10 December 2018. We included randomized trials of ≥2 weeks assessing the effect of liquid meal replacements in weight loss diets compared with traditional weight loss diets on cardiometabolic risk factors in overweight/obese subjects with type 2 diabetes. Two independent reviewers extracted relevant data and assessed risk of bias. Data were pooled using the inverse variance method. The overall certainty of the evidence was evaluated using GRADE (Grading of Recommendations Assessment, Development and Evaluation).

RESULTS

Nine trial comparisons (N = 961 [median follow-up 24 weeks]) met eligibility criteria. Mean differences were for body weight -2.37 kg (95% CI -3.30 to -1.44), BMI -0.87 kg/m² (-1.31 to -0.42), body fat -1.66% (-2.17 to -1.15), waist circumference -2.24 cm (-3.72 to -0.77), HbA_1c -0.43% (-0.66 to -0.19) (-4.7 mmol/mol [-7.2 to -2.1]), fasting glucose -0.63 mmol/L (-0.99 to -0.27), fasting insulin -11.83 pmol/L (-23.11 to -0.54), systolic blood pressure -4.97mmHg (-7.32 to -2.62), and diastolic blood pressure -1.98 mmHg (-3.05 to -0.91). There was no effect on blood lipids. The overall certainty of the evidence was low to moderate owing to imprecision and/or inconsistency.

CONCLUSIONS

Liquid meal replacements in weight loss diets lead to modest reductions in body weight, BMI, and systolic blood pressure, and reductions of marginal clinical significance in body fat, waist circumference, HbA_1c, fasting glucose, fasting insulin, and diastolic blood pressure. More high-quality trials are needed to improve the certainty in our estimates.

Pomegranate juice and extract extended lifespan and reduced intestinal fat deposition in Caenorhabditis elegans

Pomegranate juice with a high content of polyphenols, pomegranate extract, ellagic acid, and urolithin A, have anti-oxidant and anti-obesity effects in humans. Pomegranate juice extends lifespan of Drosophila melanogaster. Caenorhabditis elegans (C. elegans) (n = 6) compared to the control group in each treatment, lifespan was increased by pomegranate juice in wild type (N2, 56 %, P < 0.001) and daf-16 mutant (daf-16(mgDf50)I) (18 %, P = 0.00012), by pomegranate extract in N2 (28 %, P = 0.00004) and in daf-16(mgDf50)I (10 %, P < 0.05), or by ellagic acid (11 %, P < 0.05). Pomegranate juice reduced intestinal fat deposition (IFD) in C. elegans (n = 10) N2 (-68 %, P = 0.0003) or in the daf-16(mgDf50)I (-33 %, P = 0.0034). The intestinal fat deposition was increased by pomegranate extract in N2 (137 %, P < 0.0138) and in daf-16(mgDf50)I (26 %, P = 0.0225), by ellagic acid in N2 (66 %, P < 0.0001) and in daf-16(mgDf50)I (74 %, P < 0.0001), or by urolithin A in N2 (57 %, P = 0.0039) and in daf-16(mgDf50)I (43 %, P = 0.0001). These effects were partially mediated by the daf-16 pathway. The data may offer insights to human aging and obesity due to homology with C. elegans.

Effects of meal replacement therapy on metabolic outcomes in Thai patients with type 2 diabetes: A randomized controlled trial

Background:

A meal replacement (MR) with a low glycemic index (GI) is possibly beneficial for glycemic control. However, the effects of MR on diabetes mellitus have not been studied among Thai patients with type 2 diabetes (T2DM).

Aim:

To compare metabolic outcomes between T2DM patients receiving the new MR formula (ONCE PRO) and normal controlled diets.

Methods:

A multicenter, open-labeled, randomized controlled trial was conducted. Eligible patients received either ONCE PRO for one meal daily with controlled diets or only controlled diets for 3 months. The differences in metabolic profile between the baseline and end point of each group and between groups were measured.

Results:

110 participants were enrolled; the mean difference and standard deviation in hemoglobin A1C (HbA1c) (%) from baseline were –0.21 ± 0.78 (p = 0.060) and –0.27 ± 0.60 (p = 0.001) in the MR and control groups, respectively; however, there was no significant difference between groups (p = 0.637). Patients consuming a MR instead of breakfast had a significant decrease in HbA1c (p = 0.040). Body weight (BW) and body mass index (BMI) were significantly reduced in both groups. There were no significant change in waist circumference, fasting plasma glucose, total cholesterol and triglycerides. Low-density lipoprotein cholesterol (LDL-C) was significantly decreased in the MR group compared with the control group (p = 0.049).

Conclusions:

Short-term conventional diet control and the low-GI MR product were associated with a decreased BW and BMI. Changes in the other metabolic outcomes, HbA1c, total cholesterol and triglycerides, were comparable despite ONCE PRO as the MR having a better effect on LDL-C lowering.

Diet Behavior Change Techniques in Type 2 Diabetes: A Systematic Review and Meta-analysis

OBJECTIVE

Dietary behavior is closely connected to type 2 diabetes. The purpose of this meta-analysis was to identify behavior change techniques (BCTs) and specific components of dietary interventions for patients with type 2 diabetes associated with changes in HbA_1c and body weight.

RESEARCH DESIGN AND METHODS

The Cochrane Library, CINAHL, Embase, PubMed, PsycINFO, and Scopus databases were searched. Reports of randomized controlled trials published during 1975-2017 that focused on changing dietary behavior were selected, and methodological rigor, use of BCTs, and fidelity and intervention features were evaluated.

RESULTS

In total, 54 studies were included, with 42 different BCTs applied and an average of 7 BCTs used per study. Four BCTs-"problem solving," "feedback on behavior," "adding objects to the environment," and "social comparison"-and the intervention feature "use of theory" were associated with >0.3% (3.3 mmol/mol) reduction in HbA_1c. Meta-analysis revealed that studies that aimed to control or change the environment showed a greater reduction in HbA_1c of 0.5% (5.5 mmol/mol) (95% CI -0.65, -0.34), compared with 0.32% (3.5 mmol/mol) (95% CI -0.40, -0.23) for studies that aimed to change behavior. Limitations of our study were the heterogeneity of dietary interventions and poor quality of reporting of BCTs.

CONCLUSIONS

This study provides evidence that changing the dietary environment may have more of an effect on HbA_1c in adults with type 2 diabetes than changing dietary behavior. Diet interventions achieved clinically significant reductions in HbA_1c, although initial reductions in body weight diminished over time. If appropriate BCTs and theory are applied, dietary interventions may result in better glucose control.

Effect of weight reduction on glycated haemoglobin in weight loss trials in patients with type 2 diabetes

AIM

To quantify the effect of weight loss on glycated haemoglobin (HbA1c) at group level, based on data from published weight loss trials in overweight and obese patients with type 2 diabetes (T2D).

METHODS

A systematic literature search in MEDLINE, EMBASE and Cochrane CENTRAL (January 1990 through December 2012) was conducted to identify prospective trials of energy-reduced diets, obesity drugs or bariatric surgery in adult, overweight and obese patients with T2D. Based on clinical data with follow-up from 3 to 24 months, a linear model was developed to describe the effect of weight reduction on HbA1c.

RESULTS

The literature search identified 58 eligible articles consisting of 124 treatment groups and 17 204 subjects, yielding a total of 250 data points with concurrent mean changes from baseline in weight and HbA1c. The model-based analyses indicated a linear relationship between weight loss and HbA1c reduction, with an estimated mean HbA1c reduction of 0.1 percentage points for each 1 kg of reduced body weight for the overall population. Baseline HbA1c was a significant covariate for the relationship between weight loss and HbA1c: high HbA1c at baseline was associated with a greater reduction in HbA1c for the same degree of weight loss. The collected trial data also indicated weight-loss-dependent reductions in antidiabetic medication.

CONCLUSIONS

At group level, weight loss in obese and overweight patients with T2D was consistently accompanied by HbA1c reduction in a dose-dependent manner. The model developed in the present study estimates that for each kg of mean weight loss, there is a mean HbA1c reduction of 0.1 percentage points. HbA1c-lowering is greater in populations with poor glycaemic control than in well controlled populations with the same degree of weight loss. This summary of data from previous trials regarding the effect of weight reduction on HbA1c may be used to support the design and interpretation of future studies that aim to demonstrate the efficacy of weight loss interventions for T2D treatment.

A systematic review of commercial weight loss programmes' effect on glycemic outcomes among overweight and obese adults with and without type 2 diabetes mellitus

OBJECTIVE

We examined the glycemic benefits of commercial weight loss programmes as compared with control/education or counselling among overweight and obese adults with and without type 2 diabetes mellitus (T2DM).

METHODS

We searched MEDLINE, Cochrane Database of Systematic Reviews, and references cited by individual programmes. We included randomized controlled trials of ≥12 weeks duration. Two reviewers extracted information on study design, population characteristics, interventions, and mean changes in haemoglobin A1c and glucose.

RESULTS

We included 18 randomized controlled trials. Few trials occurred among individuals with T2DM. In this population, Jenny Craig reduced A1c at least 0.4% more than counselling at 12 months, Nutrisystem significantly reduced A1c 0.3% more than counselling at 6 months, and OPTIFAST reduced A1c 0.3% more than counselling at 6 months. Among individuals without T2DM, few studies evaluated glycemic outcomes, and when reported, most did not show substantial reductions.

DISCUSSION

Few trials have examined whether commercial weight loss programmes result in glycemic benefits for their participants, particularly among overweight and obese individuals without T2DM. Jenny Craig, Nutrisystem and OPTIFAST show promising glycemic lowering benefits for patients with T2DM, although additional studies are needed to confirm these conclusions. © 2016 World Obesity.

Transcultural Diabetes Nutrition Algorithm: Brazilian Application

The prevalence of obesity, pre-diabetes, and type 2 diabetes (T2D) is increasing worldwide, especially in the developing nations of South America. Brazil has experienced an exponential increase in the prevalence of these chronic non-communicable diseases. The rising prevalence is probably due to changing eating patterns, sedentary living, and a progressive aging of the population. These trends and their underlying causes carry untoward consequences for all Brazilians and the future of Brazilian public health and the healthcare system. Lifestyle changes that include healthy eating (nutrition therapy) and regular physical activity (structured exercise) represent efficient inexpensive measures to prevent and/or treat the aforementioned disorders and are recommended for all afflicted patients. Regrettably, the implementation of lifestyle changes is fraught with clinical and personal challenges in real life. The transcultural Diabetes Nutrition Algorithm (tDNA) is a therapeutic tool intended to foster implementation of lifestyle recommendations and to improve disease-related outcomes in common clinical settings. It is evidence-based and amenable to cultural adaptation. The Brazilian Diabetes Association, Society of Cardiology and Ministry of Health guidelines for nutrition therapy and physical exercise were considered for the Brazilian adaptation. The resultant tDNA-Brazil and its underlying recommendations are presented and explained.

Efficacy of commercial weight-loss programs: an updated systematic review

BACKGROUND

Commercial and proprietary weight-loss programs are popular obesity treatment options, but their efficacy is unclear.

PURPOSE

To compare weight loss, adherence, and harms of commercial or proprietary weight-loss programs versus control/education (no intervention, printed materials only, health education curriculum, or <3 sessions with a provider) or behavioral counseling among overweight and obese adults.

DATA SOURCES

MEDLINE and the Cochrane Database of Systematic Reviews from inception to November 2014; references identified by program staff.

STUDY SELECTION

Randomized, controlled trials (RCTs) of at least 12 weeks' duration; prospective case series of at least 12 months' duration (harms only).

DATA EXTRACTION

Two reviewers extracted information on study design, population characteristics, interventions, and mean percentage of weight change and assessed risk of bias.

DATA SYNTHESIS

We included 45 studies, 39 of which were RCTs. At 12 months, Weight Watchers participants achieved at least 2.6% greater weight loss than those assigned to control/education. Jenny Craig resulted in at least 4.9% greater weight loss at 12 months than control/education and counseling. Nutrisystem resulted in at least 3.8% greater weight loss at 3 months than control/education and counseling. Very-low-calorie programs (Health Management Resources, Medifast, and OPTIFAST) resulted in at least 4.0% greater short-term weight loss than counseling, but some attenuation of effect occurred beyond 6 months when reported. Atkins resulted in 0.1% to 2.9% greater weight loss at 12 months than counseling. Results for SlimFast were mixed. We found limited evidence to evaluate adherence or harms for all programs and weight outcomes for other commercial programs.

LIMITATION

Many trials were short (<12 months), had high attrition, and lacked blinding.

CONCLUSION

Clinicians could consider referring overweight or obese patients to Weight Watchers or Jenny Craig. Other popular programs, such as Nutrisystem, show promising weight-loss results; however, additional studies evaluating long-term outcomes are needed.

PRIMARY FUNDING SOURCE

None. (

PROSPERO

CRD4201-4007155).

Optimal diabetes management during medical weight loss for cardiovascular risk reduction

Obesity has long been recognized as a significant risk factor for type 2 diabetes. Both obesity and type 2 diabetes are associated with an increase in cardiovascular risk. As cardiovascular disease continues to be the number one killer in the USA and western adult populations, the rise in prevalence of obesity and type 2 diabetes is alarming. This is especially disturbing in the tripling of overweight children and adolescents, accompanied by the increase in prevalence of pediatric type 2 diabetes. Optimal strategies for long-term diabetes management aim at effectively controlling, reducing and ultimately preventing obesity. This review explores the clinical recommendations in place, new clinical investigations, diet therapy, medical nutrition therapy, meal replacements, behavior therapy, exercise therapy, pharmacotherapy and surgical therapy as strategies to achieve weight-loss success in diabetic patients and ultimately reduce cardiovascular disease.

Randomized controlled trial of the Medifast 5 & 1 Plan for weight loss

Objective

The Medifast 5 & 1 Plan (MD) is a portion-controlled, nutritionally-balanced, low-fat weight-loss plan. We studied the effects of MD compared with a reduced-energy, food-based diet (FB) on body weight, waist circumference, fat mass, and other measures in adults.

Design

We conducted a 2 parallel-arm, randomized, controlled trial comparing MD to FB over 52 weeks. A total of 120 men and women aged 19-65 years with BMI ≥35 and ≤50 kg/m² were randomized to MD (n = 60) or FB (n = 60). Follow-up included a 26-week weight-loss phase and 26-week weight-maintenance phase. Anthropometric, body composition, biochemical, and appetite/satiety measures were performed at baseline, 26 and 52 weeks. An intention-to-treat, linear mixed models analysis was the primary analysis.

Results

Fifty MD subjects (83.3%) and 45 FB subjects (75.0%) completed the study on assigned treatment. At 26 weeks, race-adjusted mean weight loss was 7.5 kg in MD subjects vs. 3.8 kg in FB subjects (P = 0.0002 for difference); reduction in waist circumference was 5.7 cm in MD vs. 3.7 cm in FB (P = 0.0064); and fat mass loss was 6.4 kg in MD vs. 3.7 kg in FB (P = 0.0011). At 52 weeks, the corresponding reductions were 4.7 vs. 1.9 kg (P = 0.0004); 5.0 vs. 3.6 cm (P = 0.0082); and 4.1 vs. 1.9 kg (P = 0.0019) in MD and FB subjects, respectively.

Conclusion

In obese adults, MD resulted in significantly greater reductions in body weight and fat compared with an FB diet for one year after randomization.

How best to use partial meal replacement in managing overweight or obese patients with poorly controlled type 2 diabetes

OBJECTIVE

To compare patient compliance and benefits, over 12 months, of 1 versus 2 partial meal replacement (PMR) for the management of overweight/obese subjects with inadequately controlled type 2 diabetes.

DESIGN AND METHODS

Thirty-six overweight patients with inadequately controlled type 2 diabetes (BMI > 27 kg/m(2) and HbA1c > 7.5% [58 mmol/mol]) were randomized to receive 1 or 2 PMR/day, while maintaining usual lifestyle. Subjects were seen monthly and adjustment of medications was made to prevent hypoglycemia. Compliance was assessed by counting unused sachets.

RESULTS

Patients on 2 PMR/day lost almost 4 kg compared with only 0.5 kg in the 1 PMR/day group. This difference was statistically significant (P < 0.05). Overall PMR was about 30% as effective as in our previous study on total meal replacement. Reductions in weight, waist, and HbA1c were better in the 2 PMR/day group while patient dropout and compliance were not worse over a 12-month period.

CONCLUSION

PMR provides a further management option for overweight/obese individuals with type 2 diabetes. The initial recommendation should be 2 PMR/day.

Meal replacements for weight loss in type 2 diabetes in a community setting

Background. There is limited information on the effectiveness of meal replacements (MRs) as a weight-loss strategy in an unsupervised community setting. Aim. To evaluate the use of MR compared with a diet book for 6 months. Subjects and Methods. Obese subjects (n = 120) with type 2 diabetes mellitus were recruited from the community in Adelaide, South Australia, and randomised to intervention or control. Subjects in the intervention were advised to consume 2 MR/day for 3 months and 1 MR/day for 3 months and follow the manufacturers' instructions from printed material and the website. Subjects in the control arm were given a commercially available diet book. Results. Consumption of 2 MR for 3 months and 1 MR for the subsequent 3 months led to weight loss of 5.5 kg (5%) and a 0.26% decrease in HbA1c while the diet book group had a weight loss of 3 kg (3%) (P = 0.027 for difference between groups) and a decrease in HbA1c of 0.15% (between group ns) in those who completed the 6-month study. On intention-to-treat (last observation carried forward) weight loss at 6 months was 3.4 kg in MR and 1.8 kg in control (P = 0.07). Decreases in HbA1c were 0.22% and 0.12%, respectively (P = ns). HDL cholesterol increased by 4% in MR and decreased by 1% in control (P = 0.004). Blood pressure decreased equally in both groups. There were reductions in fasting glucose in both groups at 6 months with no changes in LDL-cholesterol or triglyceride concentrations. Conclusion. MR confers benefits in HbA1C reduction and weight loss at 6 months in those who completed the study.

Surgeon's Requirement for Obesity Reduction: Its Influence on Weight Loss

The objective of this study was to examine whether preoperative recommendation for specific reductions in body mass index (BMI) influenced weight loss in obese surgical patients. We retrospectively reviewed the electronic medical records of 48 patients who enrolled between January 2007 to June 2010 in an 800-calorie per day liquid meal replacement (LMR) weight loss program. Of these, 9 patients (surgical group) enrolled as a result of general surgeon-directed weight loss to enable nonbariatric surgery and 39 enrolled seeking weight loss (medical group). Patients enrolled in the LMR program before bariatric surgery were excluded from analysis. All patients were seen in the setting of a comprehensive weight loss program supervised by a medical bariatrician and followed for a period of 4 months. There were no significant differences in mean initial BMI between surgical and medical patients (41.7 ± 4.55 and 41.6 ± 8.54 kg/m2, respectively) or participation time in the weight loss program (120 days vs 133 days). Of the nine surgical patients, only five (56%) reached their weight goal and underwent the planned surgical procedure. Weight loss was significantly less in the surgical compared with medical patients (BMI reduction 4.03 ± 3.99 vs 7.75 ± 4.90 kg/m2, respectively; P < 0.05). Weight loss was significantly lower in patients directed to undergo BMI reduction to enable a general surgical procedure. Future studies are needed to assess factors influencing weight loss (metabolism, exercise capacity, motivation) in patients requiring weight loss to enable a surgical procedure.

Lower postprandial glucose responses at baseline and after 4 weeks use of a diabetes-specific formula in diabetes type 2 patients

AIMS

To determine whether lower postprandial glucose (PPG) levels after intake of a diabetes-specific formula (DSF) compared with a standard formula were maintained after 4 weeks use.

METHODS

Randomized, controlled, double-blind, parallel-group study. Forty-four type 2 diabetes patients on oral anti-diabetes medication consumed 2×200mL/day of a DSF (Diasip(®)) or an isocaloric standard, fiber-containing formula for 4 weeks. PPG responses were assessed at baseline and after 4 weeks by iAUC and (delta) peak glucose concentrations.

RESULTS

PPG response was significantly lower in the DSF group after first intake and remained significantly lower after 4 weeks use. Postprandial insulin, fasting glucose, insulin resistance, fructosamine and lipid levels did not differ between groups after 4 weeks. Within the standard group, fasting glucose and HOMA(IR) significantly increased over the intervention period. Changes in body weight between groups were significantly different, with an increase in the standard group. Both products were equally well tolerated.

CONCLUSIONS

Superior PPG control by DSF was maintained after 4 weeks use, showing that this formula has added value with respect to PPG control for type 2 diabetes patients compared to a standard, fiber-containing formula. The observed effects on body weight, fasting glucose and HOMA(IR) may further support the use of a DSF.

Losing weight without dieting. Use of commercial foods as meal replacements for lunch produces an extended energy deficit

High-protein liquid meal replacements have proven to be effective in reducing caloric intake and body weight. Recently, substituting high fiber breakfast cereals for the more expensive high-protein drinks has been found to be equally effective to reduce weight. The following study tested the hypothesis that the mechanism responsible for the reduced intake was not the dietary composition of the meal replacement, but the controlled portion sized meals. Seventeen volunteers ate all of their meals and snacks from foods provided by the research unit from Monday to Friday for five consecutive weeks. For the first week, all participants selected their food from a buffet where each food was weighed before and after eating. For the next two weeks, half of the group selected their lunch by choosing one food from a selection of six commercially available portion controlled foods. They could eat as much as they wished at other meals or snacks. For final weeks four and five, the conditions were reversed for the two groups. Consuming the portion controlled lunches resulted in about a 250 kcal reduction in energy intake. More importantly, no sign of caloric compensation was evident across the 10 days of testing, an observation substantiated by a significant loss of body weight. The results suggest that the mere substitution of one smaller portioned meal each day is sufficient to cause reduction in daily energy intake and a significant amount of weight.

Evidence-based review on the effect of normal dietary consumption of fructose on blood lipids and body weight of overweight and obese individuals

Although some investigators have hypothesized that ingestion of fructose from foods and beverages is responsible for the development of hyperlipidemia or obesity, a recent evidence-based review demonstrated that there was no relationship between the consumption of fructose in a normal dietary manner and the development of hyperlipidemia or increased weight in normal weight individuals. Because overweight and obese individuals may exhibit metabolic abnormalities such as insulin resistance, impaired glucose tolerance, hyperlipedemia, and/or alterations in gut hormones involved in appetite regulation, the findings of fructose studies performed in normal weight subjects may not be particularly relevant for overweight or obese subjects. A systematic assessment of the strength and quality of the studies and their relevance for overweight or obese humans ingesting fructose in a normal dietary manner has not been performed. The purpose of this review was to critically evaluate the existing database for a causal relationship between the ingestion of fructose in a normal, dietary manner and the development of hyperlipidemia or increased body weight in overweight or obese humans, using an evidence-based approach. The results of the analysis indicate that there is no evidence which shows that the consumption of fructose at normal levels of intake causes biologically relevant changes in triglycerides (TG) or body weight in overweight or obese individuals.

A Head-to-Head Comparison of the Postprandial Effects of 3 Meal Replacement Beverages Among People With Type 2 Diabetes

Purpose

The purpose of this study was to compare the effects of 3 meal replacement beverages on glycemic response among people with type 2 diabetes.

Methods

The study examined Glucerna® Weight Loss Shake, Slim-Fast® Shake, and Ensure® with Fiber Shake, using a prospective, 3-way, cross-over design. Eighteen subjects with type 2 diabetes drank the beverages in random order on different weeks. The volume of each beverage was adjusted to include 50 grams of carbohydrates. Glucose was measured 0 to 180 minutes postprandial. Analyses included 2-factor analysis of variance (ANOVA) for repeated measures on both factors, calculation of area under the curve (AUC), and 1-way repeated measures ANOVA of AUC.

Results

The postprandial glucose profiles of the shakes differed. Glucerna® had the best profile as indicated by the graph of mean postprandial glucose levels and its lower incremental AUC. Despite the superiority of Glucerna®, 2-hour postprandial blood glucose values exceeded the ADA’s recommended upper limit for 22% of the subjects.

Conclusions

Meal replacement beverages are a popular and potentially effective option for people trying to lose or maintain weight; however, it is unknown to what degrees they affect postprandial blood glucose in people with type 2 diabetes. Because postprandial glycemic excursion is linked to cardiovascular disease, identifying a meal replacement beverage with the lowest glycemic response may mitigate some of the risks in patients with diabetes. Of the meal replacements observed in this study, Glucerna® had the smallest effect on postprandial glucose. Glycemic response to meal replacements should be monitored given product and individual variability.

Fructose and metabolic diseases: new findings, new questions

There has been much concern regarding the role of dietary fructose in the development of metabolic diseases. This concern arises from the continuous increase in fructose (and total added caloric sweeteners consumption) in recent decades, and from the increased use of high-fructose corn syrup (HFCS) as a sweetener. A large body of evidence shows that a high-fructose diet leads to the development of obesity, diabetes, and dyslipidemia in rodents. In humans, fructose has long been known to increase plasma triglyceride concentrations. In addition, when ingested in large amounts as part of a hypercaloric diet, it can cause hepatic insulin resistance, increased total and visceral fat mass, and accumulation of ectopic fat in the liver and skeletal muscle. These early effects may be instrumental in causing, in the long run, the development of the metabolic syndrome. There is however only limited evidence that fructose per se, when consumed in moderate amounts, has deleterious effects. Several effects of a high-fructose diet in humans can be observed with high-fat or high-glucose diets as well, suggesting that an excess caloric intake may be the main factor involved in the development of the metabolic syndrome. The major source of fructose in our diet is with sweetened beverages (and with other products in which caloric sweeteners have been added). The progressive replacement of sucrose by HFCS is however unlikely to be directly involved in the epidemy of metabolic disease, because HFCS appears to have basically the same metabolic effects as sucrose. Consumption of sweetened beverages is however clearly associated with excess calorie intake, and an increased risk of diabetes and cardiovascular diseases through an increase in body weight. This has led to the recommendation to limit the daily intake of sugar calories.

Weight management using a meal replacement strategy in type 2 diabetes

The growing prevalence of diabetes parallels the increased prevalence of obesity. Overweight and obese individuals with diabetes who attempt weight reduction face considerable challenges. However, several recent studies showed that weight reduction in patients with diabetes is feasible using a multidisciplinary approach that incorporates structured dietary intervention and meal replacements (MRs). Nutritionally complete MRs are shown to be useful at the start of weight reduction programs and for weight maintenance because of their nutrition adequacy. However, patients using this approach need to monitor their blood glucose levels closely and may need to adjust their diabetes medications. Most commercial MRs are currently fortified with vitamins and minerals to prevent long-term deficiency in essential micronutrients that are commonly seen in low-calorie diet plans. They also come in different flavors and formats that improve their general acceptability. To successfully initiate weight loss, MRs are generally used as absolute replacement of an agreed upon number of meals/snacks. This article covers the use of MRs for patients with diabetes for short-term and long-term weight reduction in clinical trials and real-world clinical practice.

Is sugar consumption detrimental to health? A review of the evidence 1995-2006

Many countries set quantitative targets for added sugars, justifying this by expressing concern about the likely impact of sugar on weight control, dental health, diet quality, or metabolic syndrome. This review considers whether current intakes of sugar are harmful to health, and analyses recent literature using a systematic approach to collate, rank, and evaluate published studies from 1995-2006. Results from high quality obesity studies did not suggest a positive association between body mass index and sugar intake. Some studies, specifically on sweetened beverages, highlighted a potential concern in relation to obesity risk, although these were limited by important methodological issues. Diet adequacy appeared to be achieved across sugar intakes of 6 to 20% energy, depending on subject age. Studies on metabolic syndrome reported no adverse effects of sugar in the long-term, even at intakes of 40-50% energy. The evidence for colorectal cancer suggested an association with sugar, but this appeared to have been confounded by energy intake and glycemic load. There was no credible evidence linking sugar with attention-deficit, dementia, or depression. Regarding dental caries, combinations of sugar amount/frequency, fluoride exposure, and food adhesiveness were more reliable predictors of caries risk than the amount of sugar alone. Overall, the available evidence did not support a single quantitative sugar guideline covering all health issues.

Meal replacements and energy balance

Induction and maintenance of a period of negative energy balance are required for overweight and obese subjects to lose weight. Meal replacements, particularly in beverage form, have now evolved as part of the "toolbox" used by researchers and clinicians to achieve negative energy balance. This overview traces the historical development of beverage meal replacements, reviews key studies supporting their clinical efficacy, and examines concerns related to their safe use. This collective information supports the view that meal replacements, particularly in beverage form, are now an effective and safe component for use in the clinical setting. Further studies are needed to identify those subjects most likely to benefit from use of meal replacements as part of their comprehensive weight control program.

Metabolic effects of fructose and the worldwide increase in obesity

While virtually absent in our diet a few hundred years ago, fructose has now become a major constituent of our modern diet. Our main sources of fructose are sucrose from beet or cane, high fructose corn syrup, fruits, and honey. Fructose has the same chemical formula as glucose (C(6)H(12)O(6)), but its metabolism differs markedly from that of glucose due to its almost complete hepatic extraction and rapid hepatic conversion into glucose, glycogen, lactate, and fat. Fructose was initially thought to be advisable for patients with diabetes due to its low glycemic index. However, chronically high consumption of fructose in rodents leads to hepatic and extrahepatic insulin resistance, obesity, type 2 diabetes mellitus, and high blood pressure. The evidence is less compelling in humans, but high fructose intake has indeed been shown to cause dyslipidemia and to impair hepatic insulin sensitivity. Hepatic de novo lipogenesis and lipotoxicity, oxidative stress, and hyperuricemia have all been proposed as mechanisms responsible for these adverse metabolic effects of fructose. Although there is compelling evidence that very high fructose intake can have deleterious metabolic effects in humans as in rodents, the role of fructose in the development of the current epidemic of metabolic disorders remains controversial. Epidemiological studies show growing evidence that consumption of sweetened beverages (containing either sucrose or a mixture of glucose and fructose) is associated with a high energy intake, increased body weight, and the occurrence of metabolic and cardiovascular disorders. There is, however, no unequivocal evidence that fructose intake at moderate doses is directly related with adverse metabolic effects. There has also been much concern that consumption of free fructose, as provided in high fructose corn syrup, may cause more adverse effects than consumption of fructose consumed with sucrose. There is, however, no direct evidence for more serious metabolic consequences of high fructose corn syrup versus sucrose consumption.

Dietary fructose and glucose differentially affect lipid and glucose homeostasis

Absorbed glucose and fructose differ in that glucose largely escapes first-pass removal by the liver, whereas fructose does not, resulting in different metabolic effects of these 2 monosaccharides. In short-term controlled feeding studies, dietary fructose significantly increases postprandial triglyceride (TG) levels and has little effect on serum glucose concentrations, whereas dietary glucose has the opposite effects. When dietary glucose and fructose have been directly compared at approximately 20-25% of energy over a 4- to 6-wk period, dietary fructose caused significant increases in fasting TG and LDL cholesterol concentrations, whereas dietary glucose did not, but dietary glucose did increase serum glucose and insulin concentrations in the postprandial state whereas dietary fructose did not. When fructose at 30-60 g ( approximately 4-12% of energy) was added to the diet in the free-living state, there were no significant effects on lipid or glucose biomarkers. Sucrose and high-fructose corn syrup (HFCS) contain approximately equal amounts of fructose and glucose and no metabolic differences between them have been noted. Controlled feeding studies at more physiologic dietary intakes of fructose and glucose need to be conducted. In our view, to decrease the current high prevalence of obesity, dyslipidemia, insulin resistance, and diabetes, the focus should be on restricting the intake of excess energy, sucrose, HFCS, and animal and trans fats and increasing exercise and the intake of vegetables, vegetable oils, fish, fruit, whole grains, and fiber.

The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus

OBJECTIVE

Dietary carbohydrate is the major determinant of postprandial glucose levels, and several clinical studies have shown that low-carbohydrate diets improve glycemic control. In this study, we tested the hypothesis that a diet lower in carbohydrate would lead to greater improvement in glycemic control over a 24-week period in patients with obesity and type 2 diabetes mellitus.

RESEARCH DESIGN AND METHODS

Eighty-four community volunteers with obesity and type 2 diabetes were randomized to either a low-carbohydrate, ketogenic diet (<20 g of carbohydrate daily; LCKD) or a low-glycemic, reduced-calorie diet (500 kcal/day deficit from weight maintenance diet; LGID). Both groups received group meetings, nutritional supplementation, and an exercise recommendation. The main outcome was glycemic control, measured by hemoglobin A1c.

RESULTS

Forty-nine (58.3%) participants completed the study. Both interventions led to improvements in hemoglobin A1c, fasting glucose, fasting insulin, and weight loss. The LCKD group had greater improvements in hemoglobin A1c (-1.5% vs. -0.5%, p = 0.03), body weight (-11.1 kg vs. -6.9 kg, p = 0.008), and high density lipoprotein cholesterol (+5.6 mg/dL vs. 0 mg/dL, p < 0.001) compared to the LGID group. Diabetes medications were reduced or eliminated in 95.2% of LCKD vs. 62% of LGID participants (p < 0.01).

CONCLUSION

Dietary modification led to improvements in glycemic control and medication reduction/elimination in motivated volunteers with type 2 diabetes. The diet lower in carbohydrate led to greater improvements in glycemic control, and more frequent medication reduction/elimination than the low glycemic index diet. Lifestyle modification using low carbohydrate interventions is effective for improving and reversing type 2 diabetes.

Interpreting the Joslin Diabetes Center and Joslin Clinic Clinical Nutrition Guideline for Overweight and Obese Adults With Type 2 Diabetes

Interpreting the Joslin Diabetes Center and Joslin Clinic Clinical Nutrition Guideline for Overweight and Obese Adults with Type 2 Diabetes, Prediabetes, or at High Risk for Developing Type 2 Diabetes is a weight loss approach to assist health care providers in a clinical setting when counseling overweight individuals. It recommends an individualized weight reduction plan consisting of a lower carbohydrate, moderate protein, and fat diet, with specific activity and behavior modification guidelines.

The evolution of very-low-calorie diets: an update and meta-analysis

OBJECTIVE

Very-low-calorie diets (VLCDs), providing <800 kcal/d, have been used since the 1970s to induce rapid weight loss. Previous reviews of the literature have disagreed concerning the relative efficacy of VLCDs vs. conventional low-calorie diets (LCDs) for achieving long-term weight loss.

RESEARCH METHODS AND PROCEDURES

We sought to update findings on the clinical use, safety, and efficacy of VLCDs and to perform a meta-analysis of randomized trials that compared the long-term efficacy of LCDs and VLCDs. Original research articles were retrieved by a Medline search and from prior reviews of VLCDs. Trials were included only if they were randomized comparisons of LCDs and VLCDs and included a follow-up assessment at least 1 year after maximum weight loss. Data were abstracted by both authors regarding: duration of VLCD, total length of treatment, attrition, short- and long-term weight loss, changes in weight-related comorbidities, and adverse effects.

RESULTS

Six randomized trials were found that met inclusion criteria. VLCDs, compared with LCDs, induced significantly greater short-term weight losses (16.1 +/- 1.6% vs. 9.7 +/- 2.4% of initial weight, respectively; p = 0.0001) but similar long-term losses (6.3 +/- 3.2% vs. 5.0 +/- 4.0%, respectively; p > 0.2). Attrition was similar with VLCD and LCD regimens.

DISCUSSION

VLCDs did not produce greater long-term weight losses than LCDs. In the United States, the use of liquid meal replacements as part of a 1000 to 1500 kcal/d diet may provide an effective and less expensive alternative to VLCDs. In Europe, VLCDs are used with less intensive medical supervision than in the United States, which reduces the cost of this approach.

The Look AHEAD study: a description of the lifestyle intervention and the evidence supporting it

The Look AHEAD (Action for Health in Diabetes) study is a multicenter, randomized controlled trial designed to determine whether intentional weight loss reduces cardiovascular morbidity and mortality in overweight individuals with type 2 diabetes. The study began in 2001 and is scheduled to conclude in 2012. A total of 5145 participants have been randomly assigned to a lifestyle intervention or to an enhanced usual care condition (i.e., diabetes support and education). This article describes the lifestyle intervention and the empirical evidence to support it. The two principal intervention goals are to induce a mean loss >or = 7% of initial weight and to increase participants' moderately intense physical activity to > or =175 min/wk. For the first 6 months, participants attend one individual and three group sessions per month and are encouraged to replace two meals and one snack a day with liquid shakes and meal bars. From months 7 to 12, they attend one individual and two group meetings per month and continue to replace one meal per day (which is recommended for the study's duration). Starting at month 7, more intensive behavioral interventions and weight loss medication are available from a toolbox, designed to help participants with limited weight loss. In Years 2 to 4, treatment is provided mainly on an individual basis and includes at least one on-site visit per month and a second contact by telephone, mail, or e-mail. After Year 4, participants are offered monthly individual visits. The intervention is delivered by a multidisciplinary team that includes medical staff who monitor participants at risk of hypoglycemic episodes.

Nutrition therapy for overweight children and adolescents with type 2 diabetes

The increased number of children and adolescents diagnosed with type 2 diabetes presents new challenges to pediatricians, nurses, and dietitians. Treatment with medications and lifestyle changes is similar to that for adults with type 2 diabetes, but must be developmentally appropriate for children and adolescents. Registered dieticians must apply knowledge from treatment for overweight children and adolescents without diabetes with treatment for adults with type 2 diabetes to provide effective nutrition therapy for this population.

The role of meal replacements in obesity treatment

Effective weight loss strategies are needed to help overweight and obese people lose weight and maintain weight loss in the long term. Meal replacements for weight loss are available in the community; however, their efficacy in the longer term is not clear. This review summarizes recent evidence on the use of meal replacements as a weight loss strategy.

Long-term efficacy of soy-based meal replacements vs an individualized diet plan in obese type II DM patients: relative effects on weight loss, metabolic parameters, and C-reactive protein

BACKGROUND

Achieving significant weight loss and glycemic control in diabetic patients remains a challenging task.

OBJECTIVE

This study compared the effects of a soy-based meal replacement (MR) plan vs an individualized diet plan (IDP; as recommended by the American Diabetes Association) on weight loss and metabolic profile.

DESIGN/SUBJECTS

A total of 104 subjects were randomized prospectively to the two treatments for a total of 12 months.

RESULTS

In all, 77 of the 104 subjects completed the study. Percentage weight loss in MR group (4.57+/-0.81%) was significantly greater (P<0.05) than in IDP group (2.25+/-0.72%). Fasting plasma glucose was significantly reduced in MR group (126.4+/-4.9 mg/dl) compared with IDP group (152.5+/-6.6 mg/dl, P<0.0001) at 6 months but not at 12 months. Controlling for baseline levels, hemoglobin Alc level improved by 0.49+/-0.22% for those receiving MR when compared to IDP group (P<0.05). A greater number of subjects in MR group reduced their use of sulfonylureas (P<0.0001) and metformin (P<0.05) as compared to IDP group. High-sensitivity C-reactive protein (hs-CRP) decreased -26.3% (P = 0.019) in MR group compared to -7.06% (P = 0.338) in IDP group at 6 months. Similar changes were observed at 12 months with MR groups, with hs-CRP decreasing by -25.0% (P = 0.019) compared to -18.7% (P = 0.179) in IDP group.

CONCLUSION

This study demonstrates that MR is a viable strategy for weight reduction in diabetic patients, resulting in beneficial changes in measures of glycemic control and reduction of medications.

Feasibility of a partial meal replacement plan for weight loss in low-income patients

BACKGROUND

Low-income patients are disproportionately affected by obesity. Routine care is available to this population at the Venice Family Clinic (VFC) in Los Angeles. The current study examined the effectiveness of nutrition clinic utilizing meal replacements (Slim-Fast, Slim-Fast Foods Co., FL, USA) in low-income patients over a 6-month period compared with the routine care by their primary care physician (PMD) prior to enrolling in the nutrition clinic at similar time intervals.

METHODS

In total, 63 patients (51 F; 49+/-0.8 yo) who had been followed at the VFC by their PMD for at least 6 months were enrolled in this study. Patients had a body mass index (BMI) of 40+/-1.1 kg/m2, were 72% Hispanic, 25% Caucasian, and 3% African American. They had the following co-morbidities: hypertension (HTN) 45%, diabetes mellitus II (DM II) 50%, gastroesophageal reflux disease (GERD) 34%, osteoarthritis 51%, and hypercholesterolemia 48%. All patients were provided with meal replacements to be taken twice a day and were instructed to consume one complete low calorie meal per day. Weights at the first visit to the nutrition clinic, 1, 3, and 6 months after enrollment in nutrition clinic were compared to their weights at the same time intervals during routine visits to their PMD prior to enrollment in the nutrition clinic.

RESULTS

There was no significant weight change during the 6 months prior to enrollment in the nutrition program despite receiving care by a PMD. At 6 months after participating in the nutrition program, there was a mean decrease of 7% body weight with a reduction in BMI from 40-37 kg/m2 (P< or =0.05).

CONCLUSION

Implementation of nutrition clinic utilizing meal replacements in this low-income patient population was effective in achieving a significant reduction in weight over 6 months of treatment..

Managing obesity and glycemic control in insulin-using patients: clinical relevance and practice recommendations

In a number of large-scale studies, intensive therapy regimens have improved glycemic control while reducing the microvascular complications of type 2 diabetes. However, insulin use has been associated with weight gain, thereby hampering patient compliance with intensive insulin therapy. As the prevalence of type 2 diabetes and obesity continues to increase worldwide, health care providers must incorporate the management of weight gain in therapeutic strategies that promote glycemic control. The central component in any such strategy is a tailored program of medical nutrition therapy (MNT), which includes a healthy diet, physical activity, and education. This article reviews several dietary options within a MNT program, including the uses of liquid meal replacements, low-glycemic index carbohydrates, and foods rich in monounsaturated fatty acids. It also provides several practice recommendations to encourage compliance in patients with type 2 diabetes who wish to manage their weight while receiving insulin therapy.

Importance of weight management in type 2 diabetes: review with meta-analysis of clinical studies

Obesity is a major risk factor for development of diabetes, and excessive energy intake is a major contributor to poor glycemic control in Type 2 diabetes. The impact of obesity on risk for diabetes as well as coronary heart disease (CHD) risk factors and the benefits of weight loss in decreasing risk for developing diabetes and improving glycemia and CHD risks were reviewed. A systematic review of the medical literature to assess the impact of obesity and weight gain on risk for diabetes and CHD was done. We performed a meta-analysis of the effects of weight loss for obese diabetic individuals. Controlled clinical trials assessing lifestyle changes on risk for developing diabetes and weight loss effects on glycemia and CHD risk factors were reviewed. Obesity and weight gain can increase risk for diabetes by greater than ninetyfold and CHD by about sixfold. Very-low-energy diets (VLED) decrease fasting plasma glucose values by approximately 50% within two weeks and these changes are sustained with continued energy restriction. Twelve weeks of energy-restricted diets were associated with these significant decreases: body weight, 9.6%; fasting plasma glucose, 25.7%; serum cholesterol, 9.2%; serum triglycerides, 26.7%; systolic blood pressure, 8.1%; and diastolic blood pressure, 8.6%. Larger weight losses were associated with larger reductions in these values. The reviewed data suggest that US health care providers should endorse the American Heart Association's and European diabetes associations' recommendations that diabetic persons achieve and maintain a BMI of Collapse

Key Words Collapse

MESH Headings

• Body Weight/physiology
• Coronary Disease/etiology
• Coronary Disease/prevention & control
• Diabetes Complications
• Diabetes Mellitus/physiopathology
• Diabetes Mellitus, Type 2/complications
• Diabetes Mellitus, Type 2/etiology
• Diabetes Mellitus, Type 2/prevention & control
• Humans
• Obesity/complications
• Obesity/physiopathology
• Risk Factors
• Weight Loss

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Grants Collapse

Affiliation(s)

James W Anderson Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, USA.
Cyril W C Kendall
David J A Jenkins

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Practical Office Strategies for Weight Management of the Obese Diabetic Individual

SUMMARY

Obesity is a key component of the insulin-resistance syndrome of type 2 diabetes, and intensifies comorbidities underlying the increased cardiovascular risk of individuals with type 2 diabetes. Weight loss leads to dramatic beneficial effects, with reductions in blood glucose levels and improvements in lipid profiles and blood pressure that often necessitate reductions in medications. Successful long-term weight loss is difficult to achieve in patients with diabetes, as standard dietary approaches often have minimal long-term impact, and intensive management strategies designed to improve glycemic control often contribute to further weight gain in these patients. This article offers a review of newer strategies for enhancing lifestyle change and weight loss in the obese diabetic individual. Use of meal replacements provides structure with portion control, and increased intake of fruits and vegetables promotes a healthier eating style for these patients. Encouraging physical activity such as walking, stair climbing, and gardening can significantly improve cardiorespiratory fitness and glycemic control, and helps patients maintain weight loss. Self-monitoring through lifestyle diaries can reinforce the healthy behaviors necessary for long-term management of obesity. Adjunctive antiobesity medication, medically-supervised intensive weight loss programs, and minimally invasive gastric bypass procedures are important options for patients unable to make significant progress with behavioral changes.

Weight management using a meal replacement strategy: meta and pooling analysis from six studies

OBJECTIVE

Although used by millions of overweight and obese consumers, there has not been a systematic assessment on the safety and effectiveness of a meal replacement strategy for weight management. The aim of this study was to review, by use of a meta- and pooling analysis, the existing literature on the safety and effectiveness of a partial meal replacement (PMR) plan using one or two vitamin/mineral fortified meal replacements as well as regular foods for long-term weight management.

DESIGN

A PMR plan was defined as a program that prescribes a low calorie (>800<or=1600 kcal/day) diet whereby one or two meals are replaced by commercially available, energy-reduced product(s) that are vitamin and mineral fortified, and includes at least one meal of regular foods. Randomized, controlled PMR interventions of at least 3 months duration, with subjects 18 y of age or older and a BMI>or=25 kg/m(2), were evaluated. Studies with self-reported weight and height were excluded. Searches in Medline, Embase, and the Cochrane Clinical Trials Register from 1960 to January 2001 and from reference lists identified 30 potential studies for analysis. Of these, six met all of the inclusion criteria and used liquid meal replacement products with the associated plan. Overweight and obese subjects were randomized to the PMR plan or a conventional reduced calorie diet (RCD) plan. The prescribed calorie intake was the same for both groups. Authors of the six publications were contacted and asked to supply primary data for analysis. Primary data from the six studies were used for both meta- and pooling analyses.

RESULTS

Subjects prescribed either the PMR or RCD treatment plans lost significant amounts of weight at both the 3-month and 1-year evaluation time points. All methods of analysis indicated a significantly greater weight loss in subjects receiving the PMR plan compared to the RCD group. Depending on the analysis and follow-up duration, the PMR group lost approximately 7-8% body weight and the RCD group lost approximately 3-7% body weight. A random effects meta-analysis estimate indicated a 2.54 kg (P<0.01) and 2.43 kg (P=0.14) greater weight loss in the PMR group for the 3-month and 1-y periods, respectively. A pooling analysis of completers showed a greater weight loss in the PMR group of 2.54 kg (P<0.01) and 2.63 kg (P<0.01) during the same time period. Risk factors of disease associated with excess weight improved with weight loss in both groups at the two time points. The degree of improvement was also dependent on baseline risk factor levels. The dropout rate for PMR and RCD groups was equivalent at 3 months and significantly less in the PMR group at 1 y. No reported adverse events were attributable to either weight loss regimen.

CONCLUSION

This first systematic evaluation of randomized controlled trials utilizing PMR plans for weight management suggests that these types of interventions can safely and effectively produce significant sustainable weight loss and improve weight-related risk factors of disease.