Meal replacements and Medical Nutrition Therapy for Weight Management

Transcription

1 Meal replacements and Medical Nutrition Therapy for Weight Management

2 Body weight management involves multiple inter-related factors Figure adapted from:

3 Potential contributors to obesity Figure adapted from:

4 AACE/ACE 2016: complications-centric model of obesity management Patients present with overweight or obesity BMI 25kg/m 2 or 23kg/m 2 in certain ethnicities, and excess adiposity Candidates for weight loss therapy Evaluate for weight-related complications Evaluate for overweight and obesity Patients Present with Weight- Related Disease or Complication Prediabetes Metabolic Syndrome Type 2 diabetes Dyslipidemia Hypertension CVD NAFLD PCOS Female infertility Male hypogonadism Depression Asthma Osteoarthritis Urinary Incontinence Gastroesophageal Reflux Obstructive Sleep Apnea Garvey et al., Endocr Pract PMID:

5 Benefits of modest weight loss 3-10% Obesity complication Weight loss required for therapeutic benefit (%) Notes Diabetes (prevention) 3-10 Maximum benefit at 10% Hypertension 5 to >15 Blood pressure still decreasing at >15% Dyslipidemia 3 to >15 Triglycerides still decreasing at >15% Hyperglycemia (elevated A1C) 3 to >15 A1C still decreasing at >15% NAFLD 10 Improves steatosis, inflammation and mild fibrosis Sleep apnea 10 Little benefit at 5% Osteoarthritis 5-10 Improves symptoms and joint stress mechanics Stress incontinence 5-10 Gastroesophageal reflex disease 5-10 in women; 10 in men Polycystic ovary syndrome 5-15 (>10 optimal) Lowers androgens, improves ovulation, increases insulin sensitivity Cefalu et al. Diabetes care. 2015;38(8):

6 Weight maintenance following lifestyle intervention is difficult to achieve 1 in 6 overweight and obese adults in the US report ever having maintained weight loss of at least 10% for 1 year Kraschnewski et al Int J Obes 2010;34:

7 Weight re-gain occurs after initial weight loss in majority of individuals obese men and obese women in UK followed over 9 years. Over the follow-up period, the majority of men and women showed subsequent weight gain after initial BMI reduction across BMI categories. A greater number of those with higher BMIs showed continued reduction Fildes et al., Am J Public Health. 2015;105: e54 e59 7

8 Weight-loss trajectories post-surgery evident from LABS data Courcoulas et al., JAMA. 2013;310(22):

9 Physiological antagonism to body weight change Weight regain promoted if upper control limit not strong then consistent increase Speakman et al. Dis Model Mech 2011;4(6):

10 Meal replacements in the weight management tool-box

11 Superior weight loss over 3 months with structured meal replacement MNT Meal replacement Control Meta-analysis of weight loss studies comparing standard dietary advice for caloric reduction against with meal replacement programs Greater weight loss in the meal replacement studies (4% versus 7%) Number of participants experiencing 5% weight loss greater in MNT programs (72% versus 34%; p<0.001) Drop-out rates comparable between groups (16% versus 19%; p = 0.407) Heymsfield et al. International Journal of Obesity 2003;26:

12 Greater proportion of weight loss responders with meal replacements Women (n=87) randomized to receive meal replacement or not for 12 weeks Rate of responders was higher in the meal replacement group 77% lost >5% body weight compared with 50% lost >5% in the control group* *p=0.010 Metzner et al. Nutrition & Metabolism 2011, 8:64

13 Superior weight loss continues at 1 year with structured meal replacement MNT Meta-analysis of weight loss studies comparing standard dietary advice for caloric reduction against with meal replacement programs Meal replacement Control At 1 year, participants in the MNT meal replacement group maintained a 7-8% weight loss compared with 3-7% across the standard caloric reduction advise studies Proportion of participants who had lost 5% body weight loss was greater in MNT program (33% versus 76%; p<0.001) Drop-out rates lower in the MNT programs than standard advice (47% versus 64%) Heymsfield et al. International Journal of Obesity 2003;26:

14 Structured programs including meal replacements leads to greater weight reduction over 1 year in participants in the Look AHEAD study Wadden et al., Obesity (Silver Spring). 2009; 17(4):

15 Increased use of meal replacements within a structured program increases weight reduction over 1 year in participants in the Look AHEAD study Wadden et al., Obesity (Silver Spring). 2009; 17(4):

16 Greater weight loss over 12 months seen with increasing use of meal replacements Body weight 1 serving 2 servings Mean SD Mean SD 3 months months Increased weight loss and reduction in waist circumference seen with 2 servings compared with 1 serving within MNT program 3 months Waist circumference 12 months Leader et al. Obesity 2013;21:

17 Phased approach to use of meal replacements within a dietetic protocol Phase I 30-days full meal replacement Phase II 30 days 3 meal replacement plus protein plate Phase III 60 days 2 meal replacement plus 2 protein plates and small amounts of CHO Phase IV 60 days 1 meal replacement plus 2 protein plates and reintroduction of CHO BMI = 33.8±3.2 kg/m 2 Age = 35.1±10.2 years 17 women, 7 men RESULTS Average weight loss was 15.4±6.7% Fat mass reduced from 32.8±4.7 to 26.1±6.3% (p<0.05) Relative increase of lean mass: 61.9±4.8 to 67.1±5.9% (p<0.05) No variations of the liver and kidney functions were found Basciani et al. Endocrine. 2015;48(3):863-70

18 Weight maintenance with meal replacement: small changes interventions Following a complete VLCD full meal replacement program, subjects self-selected from maintenance behaviors The most commonly reported daily behaviors were: Self weighing Use of meal replacements Step counting Ames et al., Eat Behav. 2014;15(1):95-8

19 Meal replacements for weight maintenance: evidence overview Meal Rep anti-ob Drug Meta-analysis: studies (n=20); participants (n=3017) Johansson et al. Am J Clin Nutr, 2014;99:14 23

20 Meal replacements for weight maintenance: evidence overview Range Months Anti-obesity drugs 3.5kg 1.5, 5.5kg Meal replacements 3.9kg 2.8, 5.9kg High-protein diets 1.5kg 0.8, Physical activity 0.8kg -1.2, Dietary supplements 0.0kg -1.4, Meta-analysis: studies (n=20); participants (n=3017) Johansson et al. Am J Clin Nutr, 2014;99:14 23

21 Use of meal replacements controls portion and calorie intake without compensation at subsequent meals Week 1 All foods eaten in research unit and weighed Week 2 and 3 Group 1: All foods eaten in research unit and weighed all meals Group 2: Meal replacement at lunch All foods eaten in research unit and weighed at other meals Week 4 and 5 Group 1: Meal replacement at lunch All foods eaten in research unit and weighed at other meals Group 2: All foods eaten in research unit and weighed all meals RESULTS Meal replacement at lunches resulted in ~250 kcal reduction in energy intake. No sign of caloric compensation was evident across the 10 days of testing Reduced calorie led to reduced body weight. Levitsky & Pacanowski. Appetite. 2011;57(2):311-7

22 Meal replacements pre-surgery: relevance for initial and revision surgery Systematic review: Fifteen studies (942 participants including 351 controls) were included, 13 studies (n = 750) in bariatric patients Commercial meal replacements are feasible, have minimal side effects and facilitate weight loss and liver shrinkage in free-living obese patients awaiting elective surgery. Adverse effects and dropout rates were minimal. Ten out of 14 studies achieved 5-10 % total weight loss. Six of six studies reporting liver volume achieved 10 % reduction. Ross et al. Obes Surg. 2016;26(6):

23 The pattern of change in liver volume, visceral adipose tissue and body weight loss Percentage (%) Reduction 80% of change in 2 weeks Colles SL, et al. Am J Clin Nutr 2006;84:304-11

24 LABS-II: pre-surgery meal replacements and postsurgery weight loss The use of meal replacements as a weight loss practice in the year prior to surgery resulted in a 3% greater weight loss at the 3-year follow-up time-point. Eaten or drank meal replacements Difference in % weight change at year 3 Difference 95% CI P 2.97 (0.10, 5.84) 0.04 Analysis of 1513 post-rygb and 509 post-agb patients at 3-years post surgery. Courcoulas et al. Surg Obes Relat Dis. 2015;11(5):

25 Meal replacements and medical nutrition therapy throughout the bariatric patient pathway Pre-surgery (weight loss) Post-surgery (weight loss) Post-surgery (maintenance) Post-surgery (weight regain) Dietary intake structure Conditionspecific management Dietary intake structure Nutrient supplementation Dietary intake structure Nutrient supplementation Weight maintenance Conditionspecific management Dietary intake structure Nutrient supplementation Promote weight loss Conditionspecific management

26 Using meal replacements for weight management in clinical practice Patient profile Over-weight (BMI>25kg/m 2 ) or obese (BMI >30kg/m 2 ) Condition-specific management, need for meal structure and nutrition education 3-6 months 6-12 months Partial meal replacement 1-2 servings per day (evidence supporting dose effect) Clinically significant weight reduction (5-10%) Continued use of meal replacements as a weight management tool Utilize ingredients with conditionspecific benefit Focus on nutrition education, promoting self-monitoring habits, modifications to food and activity environments where possible and behavior change, and adjunctive condition-specific care Enhanced weight maintenance success