VLCD of diagnosis with loss of first phase


VLCD diets (800 cal) are being advocated by Professor Roy Taylor
 as being able to achieve   significant rapid weight loss similar to that achieved
with Bariatric surgery leading to remission of T2DM.  The basis of this the fat spill over theory
that fat spills over from subcutaneous tissue into ectopic fat and he twin
cycle hypothesis that states that T2DM is the result of excess fat accumulation
in the liver and pancreas. This leads to glucotoxicity and resultant Insulin and
Lipo-toxicity leading to reduced insulin secretion in Beta cells. It postulates
that if this ectopic  fat build-up can be
  reversed as by VLCD liver and pancreatic
function can be restored.(van Wyk and Daniels, 2016)

This argues against the general belief that in T2DM Beta
cell mass gradually declines and is at 50% at time of diagnosis with loss of
first phase insulin response (10 minutes after eating) and this is irreversible.
Also traditional medical nutritional therapy has aimed been for only moderate
calorie restriction 500-1000 below maintenance and gradual weight loss.  The rapid correction of gluco and lipo-toxicity
appears to be more effective than slow resolution from more standard MNT. The major
disadvantages is  that unlike bariatric surgery
this is  not permanent and maintenance could
be an issue. (van Wyk and Daniels, 2016) 

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There seems to some be evidence for their
effectiveness of VLCD in the peer reviewed literature and in particular that
they can work in primary care.

 

Studies

 

1.      
Lim 2011 put 11 T2DM patients on 8 weeks VLCD
(600 cal diet). Beta cell function
and hepatic insulin sensitivity returned normal with associate decrease of
liver and pancreatic fat. Diabetes duration <4 year (mean 2.5 years) and BMI 25-45. 3 months after completion mean weight gain 3.1 kg with continued loss fat pancreas and no increase in liver. 7 of 11 remained in remission. (Lim et al., 2011) 2.       Steven et Taylor 2015 repeated trial VLCD (624–700 kcal) again ceasing all hypoglycaemic looking at whether the intervention would work for patients with longer duration diabetes where might expect residual beta cell function poor and beyond remission. They enrolled 29 patients 15 <4 years and 14>8 years diabetes duration. Similar weight loss was achieved by both
groups (14.8% and 14.4). 87% of short duration and 50 % of long achieved remission
after 8 weeks.  In the long duration
group despite no remission in 50% there was a significant improvement in glycaemic
control without hypoglycaemic agents. .(Steven and
Taylor, 2015)

3.     Following the 8 weeks a stepped return to iso-caloric
diet and a structured individual weight maintenance program was used to
reintroduce solid food. 1 shake was changed to a solid meal every 3 days. To
look duration of  remission Steven et al followed
up 2 group after 6 months 13 of 30 achieved FBG <7, weight remained stable with only a 900g weight gain. 40% overall, 60% short and 21% long duration remained in remission at 6 months (Steven et al., 2016) 4.       A Study published in the Lancet Dec 2017 involved a cluster randomised trial of 49 general practices in Scotland and England. Type 2 DM BMI 27-45 kg not on insulin. Total diet replacement 825-853 kcal/day for 3-5 months. This was followed by stepped food reintroduction (2-8) weeks and structured support for long-term weight loss. 149 participants.  After 12 months weight loss 15 Kg or more in 36 (24%) compared to nil in control group. Diabetes remission in 68(46%) of intervention group and 6 (4%) in control. They concluded that T2DM remission is a realistic target for primary care setting. (Lean et al., 2017) 5.       A systematic review of evidence on use VLCD in T2DM 2017 by Sellahewa et al found average weight loss 13.2 kg, mean hba1c reduction 1.4%. Significant reduction in insulin. Dropout rates ranged from 4.7-33%. No major adverse reaction except 1 MI. (Sellahewa et al., 2016) Professor Taylor believes that weight loss is dependent on the actual amount of calories consumed and not the makeup of the diet. He also believes exercise has only a small part to play initially but may be more important for long-term maintenance. Professor Taylor also that after 3 days or so on the diet patient often loses their appetite. Products like optifast makes it easier for the patient to calculate their calorie intake.   I am fact thinking about doing my own small pilot tial (not for publication) at our clinic. I would ask for 10 volunteers amongst our diabetics who might like to try it. 

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