– by Quaade, F. & Astrup, A. (1989).

Introduction

Very Low-Calorie Diet (VLCD) if it is of an adequate composition, especially with regard to protein, has long been a safe way of bringing about a considerable weight loss in obese persons within a reasonable time. We have used Nupo as a VLCD in the proper sense of the word, i.e. as the sole source of nutrition, for monthly periods. Furthermore, we use it as the mandatory base in diets of higher energy contents, usually 1000 kcal. One major reason for this is our experience that many patients do not follow a traditional diet instruction and, having done so, try to remedy this by eating less of the diet’s valuable components. Alternatively, they try to keep within the traditional diet’s overall energy frame by inserting grossly insufficient periods of total or near-total starvation. In our diets, the nutrition powder is supplemented with iso-energetic units of ordinary food and drink, each of about 63 kcal, and the portions are visualized as small pictures (“counters”) of which there are three colors: blue for items rich in protein, green for items rich in fiber, and red for sweets, fatty items, and alcoholic beverages.

As the VLCD core of the diet covers all nutritional needs, complete freedom is allowed in the patients’ choice of the 10 counters (about 630 kcal) that are allowed in the program. This regime of freedom within limits has been tested in a randomized trial and proved to reduce the dropout rate significantly. All instruction and control are done in groups, which saves resources and has obvious psychological advantages.

Methods

Thirty-eight consecutive obese persons were treated as outpatients. The treatment commenced with the VLCD formula diet Nupo (females 388 kcal, 56 g protein; males 446 kcal, 69 g protein). VLCD had no untoward effects and was continued for as long as the patient would accept. After that, the formula diet vas supplemented with ordinary items of food and drink to the level of 1000 kcal for women and 1100 kcal for men. After 5 months the data were analyzed separately according to the duration of VLCD: group 1 (n=20): VLCD for less than 2 months, and group 2 (n=18): VLCD for 2 months or more. The two groups were comparable with regard to height, absolute weight, and precentral overweight, but group 2 was somewhat older than group 1 (49,5 vs 38,3 years, P≤0.01).

Results

The weight losses of the two groups are very different. Group 1 who had given up VLCD early, lost much less weight, both in absolute and relative terms than group 2 who had more faithfully stuck to the initial VCLD regimen. The differences are significant with regard to both total weight loss and weight loss on VLCD. Group 2 lost significantly more weight, both totally (17.1 kg (7.8-40.1)) and on VLCD alone (12.3 kg (4.1-28.8)), than group 1 (8.7 kg (-1.1-19.1) and 7.3 kg (0.9-18.2). Weight losses in both groups eliminated or strongly reduced the need for a wide variety of expensive drugs: antidiabetics, diuretics, antihypertensives, analgesics, etc.

Conclusion

It is concluded that VLCD is an effective and encouraging way of starting a dieting program and that it should be continued for at least two months, as the length of the initial VLCD period related significantly to the amount of weight eventually lost.

For the full study, click here.

– by H. Hey, et al. (1987).

Introduction

The Formula diet NUPO meets all international recommendations for daily intakes of protein, essential amino and fatty acids, vitamins, minerals, and trace elements within a daily intake of only 388 kcal. A very low calorie (VLCD) regimen with NUPO as the sole source of nutrition for many months has caused great weight loss without risk in patients with severe obesity. If the prescribed amount of nutrition powder is taken it is justifiable to allow a free choice of additional foods, including less valuable items, as long as the energy allowance is small enough to induce weight loss. Renunciation of popular foods and beverages such as cake, sweets, wine, and spirits is one major reason why many patients do not attempt to diet or, if they do, show poor compliance.

For these reasons, we felt justified in evaluating a 1000 kcal (4.2 MJ) regimen in which a fundament of formula diet is obligatory while at the same time the patients are totally free to manage the remaining energy allowance. The control group was prescribed an isoenergetic conventional slimming diet. This group was allowed diethylpropion in self-governed moderate dosage. Another purpose of the trial was to test a recently developed dietary system based on visual symbols of iso-energetic units (counters).

Methods

86 patients aged between 18 and 59 years with more than 20% overweight were assigned to one of two slimming diets. The test group had an obligatory basis (388 kcal) of a complete formula diet (NUPO) and were allowed a totally free additional choice of food and drink up to 1000 kcal including sweets and alcohol. The control group had a conventional isoenergetic diet excluding all less valuable items (“empty calories”) but were permitted to take an anorectic drug. All patients were instructed and controlled in groups, which saved resources and had psychological advantages. In both regimens, dietary instructions were conducted within a new educational system based on isoenergetic, exchangeable units of everyday food and drink, visualized as illustrated symbols (counters).

Results

After 12 weeks, weight loss was insignificantly better on a conventional diet (8,9 kg) than in the test group (7,5 kg). By contrast, the latter group had better compliance, as evidenced by a significantly smaller dropout rate (p < 0,05). Repeated registration of energy intake showed that the consumption of “empty calories” was moderate in the test group, amounting to ab. 10% and that excess intake were primarily due to increased consumption of foods rich in fiber. Complaints of side effects were negligible in both groups. The counter diet system made instruction and control easy.

Conclusion

We conclude that a free qualitative food choice, made possible by the sufficiency of the formula diet as a basis, is a realistic, effective, and responsible alternative to conventional dietary treatment of obesity.

For the full study, click here.

– by T. Andersen, et al. (1986).

Introduction

Gastroplasty (GP) performed in morbidly obese patients is fraught with an unavoidable perioperative hazard, and weight loss is often unsatisfactory even in a short term. On the other hand, weight maintenance is better after GP than after diet alone. In order to increase the ultimate weight loss and reduce surgical hazards, consecutive patients of the present study received a mandatory two-step treatment: After initial very-low-calorie-diet, (VLCD) GP is performed provided a 40% reduction of overweight has been obtained by diet. GP patients selected in this way are equally assigned to vertical banded GP or to Gomez GP. Weight control and patient education are run at group meetings.

Methods

74 patients, all admitted for morbid obesity, have been included. Their median age was 34 years, their median body weight 125.1 kg and their median overweight 93% calculated according to a Scandinavian standard. They were all screened for contraindicating diseases through clinical examination, analyses of blood and urine, ECG and liver biopsy. Treatment was started simultaneously in about 35 patients at a time. The VLCD nutrition powder used, NUPO, is apportioned as five daily meals, and water is added as the vehicle. Between the 8-week periods with VLCD, a 2-week 900 Kcal diet consisting of natural high-protein, low-fat and low-carbohydrate foods is prescribed.

The VLCD programme is continued as long as a substantial weight loss is obtained. Anorexic agents are not allowed. Patients are offered operation as the second step of the programme only if a 2/5 reduction of overweight has been reached during VLCD. Horizontal and vertical GP are performed as published elsewhere. Weight control is run at group meetings together with a formalised patient education programme. Patients are seen weekly until three months after the operation, every second week until the 6th postoperative month and at least every three months thereafter.

Results

Results are preliminary, and no comparison can yet be made between the randomised subgroups. Median weight loss after the first eight weeks of VLCD was 17.9 kg (range, 3.6-38.4 kg, n = 74). The result of VLCD can at present be evaluated only for the treatment group first started (44 patients). Of these, 31 (70%, 95% confidence limits 55-83%) reached the limit for operation. Two patients (5% of patients otherwise available for surgery, 95% confidence limits 1-15%) failed after successful VLCD to appear for group meetings. Until now, 25 patients have had GP. Most patients have stabilised their weight 3 months after surgery. At this time median postoperative weight loss is 9.0 kg (range, 3.4-22.0 kg, n = 25) and median total weight loss from VLCD plus GP has reached 46.0 kg (range, 26.1-64.0 kg, n = 25). During VLCD, the only observed complication was one case of gout, quickly yielding to conventional treatment.

Conclusion

VLCD leads to immediate weight losses not significantly different from those obtained by GP. Compared with VLCD, GP seems to possess a long-term effect on food intake, making regain significantly less pronounced. A comparison of therapeutic hazards is in favour of VLCD, which is safe when carried out with a nutritionally adequate formula. Combining the good elements of both treatments has led to the present protocol, investigating a two-step regimen, in which GP is preceded by VLCD. After GP, compliance with diet is essential for weight reduction and safety. Pre-treatment with VLCD offers an opportunity to test patients’ ability to comply. It should be realised gastric obesity surgery will never succeed in patients not prepared to follow dietary advice. Through adjusting, the duration of VLCD weight loss can be individualised. This means that nearly all patients can reduce their overweight to less than 40%, which can be considered the lower limit of excess mortality from obesity. Preoperative weight reduction makes the operations much easier and safer and postoperative management simpler. Accordingly, patient satisfaction is improved.

For the full, original study, click here.