Meal replacements and Medical Nutrition Therapy for Weight Management

Body weight management involves multiple inter-related factors

Figure adapted from: http://www.shiftn.com/obesity/Full-Map.html

Potential contributors to obesity

Figure adapted from: http://www.obesity.org/obesity/resources/facts-about-obesity/infographics/potential-contributors-to-obesity

AACE/ACE 2016: complications-centric model of obesity management Patients present with overweight or obesity

BMI ≥ 25kg/m2 or ≥ 23kg/m2 in certain ethnicities, and excess adiposity

Candidates for weight loss therapy

Evaluate for weight-related complications Evaluate for overweight and obesity

Garvey et al., Endocr Pract. 2016. PMID: 7219496

Patients Present with WeightRelated Disease or Complication Prediabetes

PCOS

Metabolic Syndrome

Female infertility

Type 2 diabetes

Male hypogonadism

Dyslipidemia

Depression

Hypertension

Asthma

CVD

Osteoarthritis

NAFLD

Urinary Incontinence

Gastroesophageal Reflux

Obstructive Sleep Apnea

Benefits of modest weight loss 3-10% Obesity complication

Weight loss required for therapeutic benefit (%)

Diabetes (prevention)

3-10

Notes

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

Stress incontinence

5-10

Gastroesophageal reflex disease Polycystic ovary syndrome

Improves symptoms and joint stress mechanics

5-10 in women; 10 in men 5-15 (>10 optimal)

Cefalu et al. Diabetes care. 2015;38(8):1567-1582.

Lowers androgens, improves ovulation, increases insulin sensitivity

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;34:1644-54

6

Weight re-gain occurs after initial weight loss in majority of individuals  76704 obese men and 99791 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., 2015. Am J Public Health. 2015;105: e54–e59

7

Weight-loss trajectories post-surgery evident from LABS data

Courcoulas et al., JAMA. 2013;310(22):2416-25.

8

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):733–745

Meal replacements in the weight management tool-box

Superior weight loss over 3 months with structured meal replacement MNT 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%; p5% body weight compared with 50% lost >5% in the control group* *p=0.010

Metzner et al. Nutrition & Metabolism 2011, 8:64

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

Heymsfield et al. International Journal of Obesity 2003;26:537-549

• 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