Total diet replacement – amount, safety and sustainability of weight loss
Posted On: 30th November 2021
Professor Anthony Leeds, senior fellow at the Parker Institute, Copenhagen, and chair of TDMR Europe reviewed the characteristics and mechanism of action of total diet replacement in TDMR Europe’s webinar “Total Diet Replacement: exploring sustainable weight loss and health benefits, including diabetes remission and prevention” held on 27th October 2021. He noted that Total Diet Replacement (TDR) offers a potential additional intervention, especially to bridge the gap between weight losses of 3 to 5kg with conventional reducing diets and losses in excess of 20kg with bariatric surgery. TDR delivers fast rates of weight loss (average 1.3 to 1.5kg/week) which is highly motivating for users and can be delivered in specialist units and primary care and community settings. Safety profiles are fully published and cost-effectiveness especially in older and heavier people has been demonstrated partly through reduced costs of medications.
Prof Leeds added ‘The recent publication by Chaitong Churuangsuk and colleagues in Glasgow of a review of meta-analyses of randomised controlled trials of TDR for diabetes remission concluded that an initial weight reduction with a total diet replacement was the most effective way to achieve type 2 diabetes remission. The challenge of achieving weight maintenance afterwards is addressed by some longer-term maintenance trials such as the DiRECT diabetes remission trial and the LIGHT trial on elderly people with obesity and osteoarthritis in Copenhagen. There are published reports including one by GeorgeThom and colleagues, identifying the characteristics of ‘maintainers’ (recognising maintenance as a lifestyle not a diet, flexible control and diet vigilance) and ‘regainers’ (life stresses, negative mood states, motivational conflicts and self-regulation inconsistency) indicating a clear need to develop proven methods to address the challenges experienced by those who regain weight more easily than others after a good initial weight loss.’
On 27th October, TDMR Europe’s online seminar brought together industry stakeholders, academics and others and showed the potential role of TDR in bringing down the incidence of obesity and severity of weight related comorbidities, such as type 2 diabetes, cardiovascular disease risk factors, osteoarthritis, and obstructive sleep apnoea. The recording of the webinar will be available soon on the TDMR Europe website.
More information on TDR is available here.
Professor Anthony Leeds is senior visiting fellow at the Parker Institute, Frederiksberg Hospital, Copenhagen; adjunct professor at the International Medical University, Kuala Lumpur, Malaysia and visiting fellow at the University of Glasgow. He chairs TDMR Europe.
Total diet replacement – amount, safety and sustainability of weight loss
Parker Institute, Frederiksberg Hospital, Copenhagen, Denmark;
School of Medicine, Dentistry and Nursing, University of Glasgow, Scotland;
School of Health Sciences, International Medical University, Malaysia.
Formula 800kcal/d low calorie diets (LCD) are composed of nutritionally complete soups, shakes bars and other products, formulated to provide all needed vitamins, minerals, essential fats and protein. They are always offered with a behavioural component and physical activity guidance. When used exclusively LCD are defined as Total diet replacements (TDR) and facilitate 1–2kg weight loss weekly with metabolic improvement in glucose, insulin, blood lipids and blood pressure in people with pre-diabetes, early diabetes, advanced diabetes, osteoarthritis, psoriasis, obstructive sleep apnoea, and heart disease.
In 2016 the American Association of Clinical Endocrinologists and American College of Endocrinology Guidelines recommended target weight losses for a range of obesity co-morbidities for example 5-15% or more to achieve remission or medication dose reduction or improved control in type 2 diabetes.
Very low-calorie diets (<800kcal/d) can give rapid weight-loss especially in men, for example Johansson showed an average 18kg weight loss in 9 weeks in men with moderate and severe obstructive sleep apnoea. Christensen showed that 800kcal/d TDRs typically gave an average eight-week weight loss of 10-12 kg in elderly people with knee osteoarthritis and subsequently showed that one meal replacement or intermittent use of 800kcal/d TDR maintained most of the weight lost over 3 years in those who stayed in the programme. Continued behavioural support, physical activity and ‘rescue packages’ can play an important part in weight maintenance.
Low-calorie and very low-calorie diets are sometimes associated with fatigue initially, constipation, dizziness, and a very small increased risk of gout and very rarely gallstone events. Adjustment of anti-diabetes and antihypertension drugs has been successfully demonstrated in DiRECT and in another GP led study (DROPLET) published with medication adjustment guidelines.
Brown A, Leeds AR Very low-energy and low-energy formula diets: Effects on weight loss, obesity co-morbidities and type 2 diabetes remission – an update on the evidence for their use in clinical practice. Nutrition Bulletin 2019 44 (1) 7-24 First published: 20 February 2019| https://onlinelibrary.wiley.com/doi/epdf/10.1111/nbu.12372
Garvey WTE et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines. Endocrine Practice 2016 22 (S3) 2016 1 DOI:10.4158/EP161365.GL
Christensen P, Bliddal, Riecke BF, et al Comparison of a low-energy diet and a very low-energy diet in sedentary obese individuals: a pragmatic randomized controlled trial Clinical Nutrition 2011 1 31- 40 https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1758-8111.2011.00006.x
Johansson K, Neovius M, Lagerros YT, Harlid R, Rossner S, Granath F, Hemmingsson E. Effect of a very low-energy diet on moderate and severe obstructive sleep apnoea in obese men: a randomized controlled trial BMJ 2009; 339: b4609 doi 10.1136/bmj.b4609
Christensen P, Henricksen M, Bartels EM, et al Long-term weight-loss maintenance in obese patients with knee osteoarthritis: a randomized trial Am J Clin Nutr 2017 doi: 10.3945/ajcn.117.158543
Johansson K etal Longer term effects of very low energy diet on obstructive sleep apnoea in cohort derived from randomised controlled trial: prospective observational follow-up study BMJ 2011;342:bmj.d3017
Resources for health care professionals available on the website of the Nuffield Department of Primary Care Health Sciences https://www.phc.ox.ac.uk/research/diet-plans/tdr-resources-for-health-professionals
Magkos F, Hjorth MF, Asping S et al, A protein-supplemented very low-calorie diet does not mitigate reductions in lean mass and resting metabolic rate in subjects with overweight or obesity: a randomized controlled trial. Clinical Nutrition online 18th October 2021 doi: https://doi.org/10.1016/j.clnu.2021.10.006
Churuangsuk C et al. Diets for weight management in adults with type 2 diabetes: an umbrella review of published meta-analyses and systematic review of trials of diets for diabetes remission Diabetologia doi: 10.1007/s00125-021-05577-2. Online ahead of print 17 Nov 2021
Thom G et al. ‘I have been all in, I have been all out and I have been everything in-between’: A 2-year longitudinal qualitative study of weight loss maintenance. J Hum Nutr Diet. 2021 34:199-214 https://onlinelibrary.wiley.com/doi/epdf/10.1111/jhn.12826