VLCDs and Diabetes, Part 2

Photo by M Clock

I was on the road this weekend, hence the delay in getting this post up.

Came across a pet peeve of mine at breakfast in the hotel.

One of the most overused words of recent times is the word "Robust".  Even coffee is getting into the act!

(To be fair, I think they were honestly robust before the current "Robust" craze).

Everything is robust now, especially when it comes to satisfactory medical data, results, benefits, etc.  I think (clinically) we have borrowed this from the boardroom and the administrative side of medicine, but I feel it's getting old already. Just my opinion, for better or for worse. No paradigm shift there.

So, now for some more Robust information on non-surgical interventions for T2DM, focusing on the VCDL, or very low calorie diet.

How safe is it?  Good question.  Pretty radical concept, actually, to ingest such a low caloric count so abruptly.  Especially when you consider the average caloric load that some of our T2DM patients are ingesting on a regular basis.

VLCDs do have some risks.  The relative 'fasting' stat of a VLCD can predispose a patient to electrolyte imbalances, including Mag and K+ and Phos that could put a patient at risk for Torsades in the setting of a prolonged QT interval. Hydration is additionally very important, as renalembarassment can be an issue in a patient who may already have some degree of insufficiency from their Diabetes, with the high protein requirements of the program. We check a baseline EKG prior to initiation of the diet,  and monitor along the way in weekly follow ups for any new cardiac symptoms, and perform occasional labs to exclude any significant evolving abnormalities that could translate to increased risk.

Blood sugars themselves can become a concern, especially when BGs start to drop, at times precipitously, with the dramatically different dietary (CHO) intake.  Meds will need to be at least followed along with changing BGs, if not diminished at the onset of the program, depending on the level of pre-existent BG control (based on a recent A1C) and the medicines that are in the patient's current regimen.

Insulin will commonly be able to be cut by up to 75% when the diet starts, depending on the level of control prior to the initiation of the VLCD.  In some cases, it can be stopped at the start of the program.

PO meds, especially sulfonylureas and possibly metformin, and some GLP-1 agents, can usually be DC'd and BGs followed to determine the level of response to the program.

The weight loss that results from starting a VLCD has rapid beneficial effects on both glycemic control and reduction in cardiac risk factors, as well as steadily improving QOL (Quality of Life) scores.

QOL scores incorporate different aspects of their sense of well-being as queried in a questionnaire format.  It includes areas of physical perception of physical pain, sense of overall health, and bodily function; and a mental component of social function, their emotional role, and overall sense of mental health. Most studies show steady increase in the sores as time goes by and weight loss mounts up on a VLCD.

My previous post described how the glycemic control improves with the initiation of the VLCD, and those changes are continued and reinforced with adequate weight loss from the diet. BP improves, kidney function improves, lipids also modestly improve with weight loss. With improving BG control, less meds are needed, which can also help aid in cardiovascular function.  Inflammatory markers are reduced with weight loss as well, further decreasing overall cardiac risk.

So, whether a VLCD is utilized in a preoperative fashion to achieve required weight loss before weight loss surgery, or as part of a medical weight loss program or T2DM treatment program, the evidence points to real benefits that can lead to improved metabolic and cardiovascular markers, as well as markedly improved QOL.

Hopefully coming soon to a Bariatric center (ours) near you!

VLCDs and Diabetes, Part 1

Is this a new term to you?

VLCDs are Very Low Calorie Diets that can be used to 'treat' Diabetes, or more specifically, could be a novel aspect of both a medically or surgically managed weight loss treatment plan to target T2DM.

 These ketogenic diets are typically less than 800 calories total, with a large percentage of that caloric total coming from protein at the expense of very limited carbohydrates.

We use these diets in our Bariatric Surgery program in 2 ways.  Commonly, we use it as the means to achieving a 5-10% weight loss prior to surgery.  This is through our 'Lean and Green' diet that is overseen by our Nursing and Registered Dietitian staff, or similarly through a Medifast program that we offer and manage for our patients.

We also utilize these types of diets in the post op setting, in a patient that may need a 'jump start' to losing some weight, or has experienced some weight recidivism.  It probably goes without saying, but this limited duration (4-12 weeks average) dietary program is just a part of the behavior retraining that may be needed, along with exercise, support groups, and follow up visits to the practice for review also needed.

As the patient nears the end of  the limited term dietary intervention with the VLCD (hopefully with some momentum-building results of pounds lost to show for it), we have a pre-scheduled dietitian visit to start to put in place a return to the proper way to eat, addressing both the quantity and the quality issues of the patient's proper post-op nutrition.

Often, patients may need a brief refresher on portion sizes, optimizing quality of their diet, avoiding empty snacks and/or emotional eating, and practical ways to combat hunger.  Exercise is a key part of that 'new' lifestyle routine, and increased activity can go a long way toward aiding with increasing lean body mass, increasing resting/basal metabolic rate, improved sense of well-being, and creating that internal awareness, if you will, of self-control that comes from the discipline of getting out there and "just doing it"regularly enough to see results.

Another place where VLCDs have a role, and this was somewhat new to me, is in the non-surgical treatment of T2DM. 

Makes sense.

I viewed a webcast this week about just such a topic.  We are in the process of putting together a Medically Managed Weight Loss arm to our practice, and the information on this webcast was very intriguing to say the least.

In a multidisciplinary program, such as we have / are looking to put together for a non-surgical component to our surgical practice, VLCDs would be the replacement dietary portion of the same lifestyle interventions (exercise and behavior) that we review and reinforce in our pre-surgery or post-surgery patients that are in need of weight loss.

Let's face it, behavior is essential to weight gain, and therefore weight loss, but at a certain level - weight loss is weight loss.

The additional medical / metabolic benefits for T2DM specifically are specific to how the body handles the VLCD intervention, and how it can fairly rapidly trigger some metabolically beneficial benefits that become reinforced over time with subsequent weight loss.

By the way, in terms of weight loss, these VLCDs are reported to be at the 3-5# per week rate with some variability.

Specific to T2DM though, Studies show the improvement in glycemic control is quite rapid, and is above what would be expected from an accumulation of weight loss over time,  or the calorie restriction alone.  Very early physiologic benefit has been seen in areas of improved beta-cell function, reduced insulin resistance, decreased hepatic glucose production. In summary, in some ways similar to the near-immediate surgical effect on Diabetes that we see in our practice.

As I see this blog entry is starting to go a little longer than I thought, let's save some finishing aspects of this topic for the next entry.

In the part 2 of this entry,  we'll cover some of the potential dangers of an unmonitored VLCD, some additional nutritional and medical safety aspects that should be addressed with the program, helpful guidelines for T2DM medical management along the way, and some additional information on the weight loss benefit that comes from the dietary program that starts with the VLCD, and how that helps to maintain the favorable glycemic control for the long haul.

Good stuff.

From Truehealthyproducts.com

Is It Time To Update The NIH Standards of 1991?

From cccblog.org

The times, they are a'changing.

Or so, some will hope.

A recent Lancet Diabetes and Endocrinology editorial posed the idea that the time has come to revisit the NIH guidelines of 1991 that spawned bariatric surgery indications and defined reimbursement schedules world wide.

Inherent in those recommendations was the idea that bariatric surgeries were confined to a 'last resort' status for weight loss and comorbidity treatment. Sounds outdated and reserved in contrast to how many view these procedures as life saving and metabolically capable of doing things that no other treatment can do - alone or in combination with other modalities.

So, with ever-increasing awareness and study-proven metabolic effects and other comorbidty resolution / improvement, and consistent proof of durable weight loss from these procedures, there is a new call for revisiting the guidelines in order to capture the true demographic of those who would benefit most from surgery, and notably a weight that may fall outside current reimbursable BMI standards.

"The question now is whether the operation would benefit other people who fail to qualify based on their degree of obesity," Dr. David E. Cummings said.  Type 2 DM is a progressive, chronic, and relentless disease, "but if you have a gastric bypass, you have an 80% chance of going into full remission, <and> it's clear now that <these procedures> are effective at getting rid of diabetes in thinner people who stand to lose less weight".

"It (also) appears that patients with high fasting insulin levels (prediabetic) stand to benefit the most from bariatric surgery in terms of cardiovascular morbidity and mortality...<and> the shorter duration of diabetes the better the outcome."

Also mentioned in the article is the safety of laparoscopic bariatric surgery, with "the same safety profile as a hip replacement, and 1/10th the mortality of coronary artery bypass," said Alfons Pomp, a bariatric surgeon from the department of surgery at Weill Cornell Medical College in New York City.

It will be interesting to see if these efforts gain any traction to open the indications for surgery in those that may benefit the most from an insurer's perspective as well.  It may take a while for that to be agreed upon, and even longer before it finds its way into a reimbursable benefit for that newer class of patient.

But, it's a start...