Tuesday, February 25, 2014

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!



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