OPTIFAST VLCD™ Program
Guidelines for Diabetes
®
OPTIFAST® VLCD™ is a food for special medical purposes for the dietary
management of obesity. Must be used under medical supervision.
For healthcare professional use only.
Table of Contents
Type 1 Diabetes & OPTIFAST® VLCD™
Main points................................................................................................................................................................................ 2
Review of the evidence............................................................................................................................................................. 3
Recommendations for management....................................................................................................................................... 4
Type 1 Diabetes Case study..................................................................................................................................................... 5
Type 2 Diabetes & OPTIFAST® VLCD™
Main points................................................................................................................................................................................ 6
Review of the evidence............................................................................................................................................................. 7
Recommendations for management....................................................................................................................................... 8
Type 2 Diabetes Case study..................................................................................................................................................... 9
Medications used in Type 2 Diabetes.................................................................................................................................... 10
This evidence-based guideline has been prepared by
Dr. Daniel Fineberg BMedSci MBBS FRACP
We would also like to thank the following experts
for their contribution, feedback and review:
Clinical Associate Professor Tania Markovic MBBS PhD FRACP
Director, Metabolism & Obesity Services, Royal Prince Alfred Hospital
Dr. Sharon J Marks MBBS(Hons), FRACP
Consultant Physician in Clinical Nutrition, Monash Medical Centre
This Guideline document is a work in progress
and will continue to evolve over time.
We would appreciate any feedback or comments you
may have on how to improve the Guideline and make
it more relevant to you and your clinical practice.
The GI Symbol is your trusted guide to healthier food choices.
Foods that carry the GI Symbol meet strict nutrient criteria
and the GI value is certified as accurate.
For more information go to gisymbol.com
Further information is available on request at:
Nestlé Healthcare Nutrition, a division of Nestlé Australia Ltd,
20–24 Howleys Road, Notting Hill VIC 3168, Australia 1800 671 628.
12–16 Nicholls Lane, Parnell, Auckland, New Zealand 0800 607 662.
For more information visit optifast.com.au
1
OPTIFAST® VLCD™ Guidelines for Diabetes
Type 1 Diabetes & OPTIFAST® VLCD™
Main points:
Care needs to be taken if using OPTIFAST® VLCD™
in patients with Type 1 Diabetes (T1DM).
uu
The issue of obesity in T1DM is important for the clinician
to consider with the increasing number of patients with
T1DM and obesity.
uu
The risk of hypoglycaemia and ketosis needs to be carefully
monitored but, with appropriate insulin adjustment, there
may be less hypoglycaemia while on a VLCD because of
the reduced likelihood of insulin to carbohydrate mismatch.
uu
Glycaemic control is critical to reducing the risk of diabetic
complications. Reduction of insulin dose needs to be
matched to the change in carbohydrate and energy intake.
The established targets of glycaemia, with avoidance of
hypoglycaemia, and management of other established
cardiovascular risk factors should be priority issues
in the management of T1DM.
uu
2
Type 1 Diabetes & OPTIFAST® VLCD™
Review of the evidence:
The prevalence of obesity in T1DM is increasing
and is associated with a high incidence of vascular
(micro and macro) disease and complications.1
uu
The landmark Diabetes Control and Complications
Trial (DCCT) in T1DM showed an average 5.1kg vs 3.7kg
increase in weight with intensive insulin therapy compared
to conventional treatment.2 An 18-year follow-up of this trial
found an increase in obesity from 3.4% at baseline to
22.7% possibly due to the community rise in obesity as
well as an increase in the intensification of insulin therapy
(7% at baseline to 82% at follow-up).3
uu
Reduction in body weight is associated with an increase
in hypoglycaemia4 that may be due to a number of
factors including reduced carbohydrate intake, increased
insulin sensitivity and change in physical activity.
Although, a study on people with T1DM who were
fasted showed a transient increase in insulin resistance
due to reduced glucose oxidation.1
uu
The appetite suppressive capability of VLCDs may
be improved with the genesis of a mild ketosis.6
Adjustment of insulin dosing can be associated
with a mild ketosis with avoidance of ketoacidosis.1
Thus the ketosis seen with a VLCD should not pose
any problems for subjects with T1DM.
uu
Although previously considered a relative contraindication
to VLCDs, under diabetes specialist supervision, VLCDs
can be used with appropriate education and patient
selection in T1DM.7
uu
While there is a paucity of published data showing
the efficacy of VLCD in T1DM there is no evidence
suggesting harm with a VLCD regimen.
uu
VLCDs are associated with ketosis via the production of
acetoacetate and beta-hydroxybutyrate from breakdown
of fatty acids. The total amount of carbohydrate where
ketosis is likely to occur is between 50-200g/day.
An Intensive Phase OPTIFAST® VLCD™ regimen provides
between 50-100g/day carbohydrate. The ketone levels
seen in non-T1DM obese subjects consuming VLCDs
range between 0.33-0.72 mmol/L and is much lower
than the level seen in diabetic ketoacidosis which is
_ 3mmol/L and often much higher.5
generally >
uu
Footnotes
1
Musil F, et al. Effect of low calorie diet and controlled
fasting on insulin sensitivity and glucose metabolism
in obese patients with type 1 diabetes mellitus.
Physiological Research. 2013.
2
The effect of intensive treatment of diabetes on
the development and progression of long-term
complications in insulin-dependent diabetes mellitus:
the Diabetes Control and Complications Trial Research
Group. N Engl J Med. 1993; 329: 977–986.
3
OPTIFAST® VLCD™ Guidelines for Diabetes
3
Purnell JQ et al; DCCT/EDIC Research Group.
Circulation. 2013 Jan 15;127(2): 180-7. Circulation.
Epub 2012 Dec 4.
4
Jacobsen IB, et al. The effect of metformin in overweight
patients with type 1 diabetes and poor metabolic
control. Basic Clinical Pharmacology Toxicology.
2009:105;145-149.
5
Sumithran and Proietto. Ketogenic diets for weight loss:
A review of their principles, safety and efficacy.
Obesity Research & Clinical Practice. 2008:2,1-13.
6
McClernon et al. The Effects of a Low-Carbohydrate
Ketogenic Diet and a Low-Fat Diet on Mood,
Hunger, and Other Self-Reported Symptoms.
Obesity. 2007:15(1), 182-187.
7
Baker S et al. Effects and clinical potential of
very-low-calorie diets (VLCDs) in type 2 diabetes
Scott Baker. Diabetes Research and Clinical Practice.
(2009)85:235-242.
Type 1 Diabetes & OPTIFAST® VLCD™
Recommendations for management:
An OPTIFAST® VLCD™ Program for weight loss can be
considered in selected patients with T1DM if used with
close follow up from their diabetes specialist.
uu
It may be prudent to start with 1 or 2 meal replacements
on initiation to work out the bolus (rapid insulin) dose.
uu
The OPTIFAST® VLCD™ products contain 13-22.5g of
carbohydrate per serve. In patients who are aware
of their carbohydrate to insulin ratio, a suitable dose
adjustment should be made.
uu
One method to estimate the carbohydrate to insulin ratio
is the 500 rule where 500 is divided by the total insulin
daily dose.
uu
– For example, if the total insulin daily dose is 100 units
– Then 500/100=5
– Carbohydrate:Insulin ratio is 5
– If taking an OPTIFAST® VLCD™ replacement with
20g of carbohydrate then:
– 20/5=4
– Therefore the dose should be 4 units of rapid acting
insulin with the meal.
A reduction in the basal insulin dose should be
considered due to the expected reduction in hepatic
glucose production. On the Intensive Phase a 50%
reduction in the basal dose is a suggested starting point.
Further adjustment may be required, especially if there
is overnight or pre-meal hypoglycaemia. Patients should
not withhold or significantly reduce the basal insulin dose
without discussion with their diabetes specialist.
uu
Patients should be familiar with appropriate management
of hypoglycaemia. Patients should perform at least
4 finger prick glucose checks a day with additional
monitoring depending on the context. If the predominant
form of hypoglycaemia is a mismatch between insulin and
carbohydrate intake then a VLCD may actually improve
the situation. Patients prone to severe hypoglycaemia due
to exercise or other physiological changes are likely to still
have difficulty with their control.
uu
Patients should be counselled to avoid at risk behaviours
(e.g. driving, swimming) until they are familiar with the effect
of the OPTIFAST® VLCD™ on their glycaemic profile.
uu
Mild ketosis may be present while on the Intensive Phase
of OPTIFAST® VLCD™.
uu
– The expected level is 0.3-0.7mmol/l and this is
likely to persist while the individual remains on the
VLCD. It is unlikely that there would be an increased
risk of ketoacidosis especially if the blood glucose
remains acceptable and the insulin is taken regularly.
– If monitoring, a fingerprick ketone level > 1.0mmol/l
should be discussed with a diabetes professional.
Health professionals should be aware of the possibility
that patients may significantly reduce or withhold insulin
as a weight management strategy. The risks of this
practice may need to be discussed with your patient.
uu
Extra care should be taken soon after the diagnosis of
T1DM. Patients should be very familiar with all aspects
of self-management.
uu
OPTIFAST® VLCD™ Guidelines for Diabetes
4
Type 1 Diabetes & OPTIFAST® VLCD™
Case study
Tara is a recently married 26 year old woman with
T1DM for 10 years complicated by mild non-proliferative
retinopathy and microalbuminuria.
She weighs 100kg, has a BMI of 40kg/m2 and has
slowly continued to gain weight at about 2kg per year
since adolescence.
Her HbA1c is generally between 8-9% and she is on a
basal bolus regimen using around 120 units of insulin daily
(60 units long acting and 20 units short acting with each
meal). She has moderate hypoglycaemic levels (low 3s)
associated with symptoms. She has tried metformin but
is unable to tolerate the gastrointestinal side effects.
She finds it frustrating that the pattern of meal-time insulin
and BGL monitoring (at least 4x daily) appears to not follow
a particular pattern in that sometimes her glucose levels
are very high but at other times she has unexplained
hypoglycaemic episodes. She has seen dietitians over the past
10 years and implemented recommended dietary behaviour
but her weight has not reduced. She is screened for other
associated conditions including hypothyroidism and has
no other medical cause for insulin resistance or weight gain.
Her diabetes specialist suggests a trial of closely
monitored OPTIFAST® VLCD™ with a goal to reduce her
weight to see if it helps with controlling her average
blood glucose, avoiding mismatch in dosing causing
hypoglycaemia and achieving weight reduction.
She starts with one OPTIFAST® VLCD™ meal replacement
a day to see how to adjust her short acting insulin dose.
She has not previously determined an insulin to carbohydrate
ratio but using the 500 rule she starts with a ratio of 4.17.
She tries the Berry Crunch Bar, which contains 20.8g
carbohydrate and takes 5 units of short acting insulin, which
is about a ¼ of her usual meal time dose. She does a blood
glucose check 2 hours after the supplement to see the effect
of the dose which is higher than her recommended post
prandial target. When she next has a Berry Crunch Bar
she takes 6 units of her short acting insulin and has a better
post prandial glucose level.
She then supplements 2 meals a day while trialling a
range of the OPTIFAST® VLCD™ products to see what
she likes best. She finds that her dose is 6-7 units of rapid
acting insulin with each supplement depending on the
carbohydrate content. She starts to have some overnight
and early morning borderline low glucose levels and
reduces her long acting insulin from 60 to 40 units.
After finding that she is stable on this she decides to
embark on the Intensive Phase of OPTIFAST® VLCD™ with
3 meal replacements. She reduces her long acting insulin
to 30 units (1/2 her initial dose) and continues with 6 units
of short acting with each supplement. She does additional
monitoring before and 2hrs after each replacement meal.
She continues this for 10 days and finds that she feels quite
well on the program. Her blood glucose levels range between
4.5-10 with no hypoglycaemia. She checks her ketone level
for interest and it is 0.6mmol/L. Routine blood tests at this
time demonstrate normal renal function and no electrolyte
disturbance. After 3 weeks she has lost 6kg and due to
borderline hypoglycaemia reduces her insulin dose further.
She is able to continue the Intensive Phase for 12 weeks
by which time she has lost 20kg. Her ability to do more
physical activity increases and she feels happier with
her life. Her HbA1c has dropped to 6.2% and she is now
normoalbuminuric. Her doses are 24 units long acting,
and 4-5 units short acting with meals. She relaxes to
2 meal replacements and 1 low carbohydrate meal daily and
continues for a further 6 weeks, reducing her weight to 72kg.
She then starts a healthy normal diet with the occasional
OPTIFAST® VLCD™ supplement, usually at lunch time.
She tries to exercise regularly and usually manages
to swim or walk 1 hour daily, as she is very keen to
maintain her current weight.
She decides that if her weight increased up to 80kg
she would re-commence the Intensive Phase of the
OPTIFAST® VLCD™ Program.
5
OPTIFAST® VLCD™ Guidelines for Diabetes
Type 2 Diabetes & OPTIFAST® VLCD™
Main points:
Type 2 Diabetes (T2DM) is a common association with obesity.
Perpetuating factors common to both of these conditions
should be the focus in patients with T2DM. Tackling obesity
will help to achieve health targets, reduce further complications
and improve long term quality of life.
u
Weight loss has been shown to be directly related to
improvements in glycaemia in patients with T2DM.
u
Use of VLCD, such as OPTIFAST® VLCD™, is a well
established method of weight loss in T2DM.
u
Improvement in beta cell function and glycaemia can occur
in some patients early in the course of a VLCD, which may
be independent to weight loss, but rather related to the
reduction in energy intake.
u
Methods to improve glycaemia and reduce obesity should
be implemented as soon as possible in the course of
T2DM as it is likely to have the greatest impact on avoiding
cardiovascular and microvascular complications.
u
Transition to less obesogenic agents is recommended
by avoiding insulin or sulphonylurea therapy and adding
metformin, DPP-IV inhibitor or GLP-1 agonist therapy.
With normal eating, acarbose may be of benefit.
The emerging SGLT-2 inhibitors may also be of
benefit to both glycaemic and weight control.
u
Agents that appear to promote satiety such as the DPP-IV
inhibitors and, even moreso, GLP-1 agonists may have an
additional benefit of improving compliance with a VLCD,
or limiting intake when on a healthy regular diet.
u
OPTIFAST® VLCD™ Guidelines for Diabetes
6
Type 2 Diabetes & OPTIFAST® VLCD™
Review of the evidence:
In Australia, while other metabolic risks such as blood
pressure and total cholesterol have decreased, BMI and
mean fasting glucose have increased. In 2008 the estimated
prevalence of obesity in Australia was over 25%.8 Obesity
compounds the cardiovascular risk of diabetes and is a major
risk factor for T2DM, accounting for about 80% of cases of
T2DM, with about 80% of people with T2DM being obese.9
uu
In a recent important trial looking at the impact of lifestyle
intervention, the Look AHEAD trial had 5000 middle aged
participants with T2DM and BMI >25 kg/m2. In addition to
other lifestyle measures the caloric intake was restricted to
approximately 1200-1500kCal/d, which included the option
for OPTIFAST® VLCD™ meal replacement to achieve this.
Patients were randomised to interventional lifestyle therapy
or standard therapy for 4 years and monitored for up to 11
years. After 4 year an 8% weight loss was associated with
better measures of glycaemia and other metabolic risk
factors including blood pressure and dyslipidaemia.10
uu
Independent of weight loss, in selected patients,
early initiation of a VLCD can lead to significant
improvements in glycaemic control.11 Beta cell function
improvements can be seen with improvement in dynamic
insulin secretion, insulin production, modulation of
pulsatility and improved synchrony.12
uu
In clinical practice it is evident that a large subset of T2DM
patients who appear to have a requirement for exogenous
insulin, when exposed to inpatient care and periods of
fasting due to procedures or diagnostic tests, often require
much less insulin or manage with their endogenous
insulin function alone. The concept of pancreatic beta cell
rest for uncontrolled hyperglycaemia is increasingly popular
and often involves the use of early insulin therapy.
An additional method of islet rest can be achieved with
a VLCD. A study of 14 otherwise well subjects with T2DM
showed about 50% responding to a very low caloric intake
(<450kCal/d) and achieving a sustained acceptable
reduction in blood sugar level (<10mmol/L). A positive
response was predicted by a good response on day 2
of the diet. Other predictors of response were a shorter
duration of diabetes and higher fasting serum insulin.13
uu
A proposed mechanism for glycaemic control is that
caloric restriction leads to glycogen depletion in muscle
and liver. Restriction of carbohydrate leads to lipolysis and
the formation of ketone bodies by the liver. Together these
responses lead to reductions in hepatic glucose output via
inhibition of gluconeogenesis and reduced glycogenolysis.
High protein stimulates insulin secretion and increases satiety.
Circulating ketone bodies have also been shown to increase
satiety14. Weight loss and reduction of fat deposits in the liver,
muscle, pancreas and perivisceral space lead to reductions
in insulin resistance. Improved insulin sensitivity, dynamic
insulin secretion and reduced hepatic glucose output lead
to reductions in blood glucose levels.15
uu
A number of small studies have shown significant
benefits of VLCDs on glycaemic control in T2DM.15
A study using a VLCD for 8 weeks and tapering with
a low calorie diet for 4 weeks showed a significant
improvement in HbA1c related to the degree of weight
loss, with a >15% weight loss contributing to a lowering
of HbA1c by about 2%.16
uu
Most international guidelines on diabetes management
recommend weight loss with calorie restriction.17
Recommendation for the use of VLCDs over other diets
is limited by the lack of long term efficacy data.18 However,
there are no studies indicating long term safety concerns.
uu
The concept of metabolic memory, whereby improvement
of glucose for a period leads to sustained improvement in
outcomes, even if glycaemic control is later relaxed, has been
demonstrated in the follow-up of some of the large landmark
studies (ACCORD)19. This phenomenon was shown in a 30
day VLCD in 18 T2DM patients in which a sustained 18 month
improvement in glycaemia and other metabolic parameters
was seen, even in those patients who regained body weight.20
uu
The use of VLCD in the management of diabetic
complications is not clear. Future studies are looking at
the use of VLCDs in patients with complications such as
microalbuminuria,21 with cautious use of VLCDs and regular
monitoring of renal function, especially initially.
uu
Footnotes
WHO Noncommunicable Disease Country Profiles 2011. http://
whqlibdoc.who.int/publications/2011/9789241502283_eng.pdf
8
Obesity & type 2 Diabetes. Maggio CA, Pi-Sunyer FX.
Endocrinology and Metabolism Clinics of North America
[2003, 32(4):805-22, viii].
9
Wing RR. Long-term effects of a life- style intervention on
weight and cardio- vascular risk factors in individuals with type
2 diabetes mellitus: four-year results of the Look AHEAD trial.
Arch Intern Med. 2010;170:1566-1575.
Reversal of type 2 Diabetes: normalisation of beta cell function
in association with decreased pancreas and liver triacylglycerol.
Lim et al. Diabetologia (2011) 54:2506–2514.
12
OPTIFAST® VLCD™ Guidelines for Diabetes
Nield et al. Cochrane Review. Dietary advice for treatment
of type 2 diabetes mellitus in adults (Review).
ACCORD Study Group. 2008 Effect of intensive glucose lowering
in type 2 diabetes. NEJM 358(24):2545-59.
Jazet et al. 2004 Diabetes UK. Diabetic Medicine, 22, 52–55.
19
14
Effect of weight loss and ketosis on postprandial cholecystokinin
and free fatty acid concentrations. Delbridge et al, Am J Clin
Nutr 2008;87:1238-46.
20
Jazet, I.M. & de Craen, A.J., Sustained beneficial metabolic
effects 18 months after a 30-day very low calorie diet in
severely obese, insulin-treated patients with type 2 diabetes.
Diabetes research 2007.
21
ClinicalTrials.gov identifier: NCT01671969.
15
Baker, S., Jerums, G. & Proietto, J., 2009. Effects and clinical
potential of very-low-calorie diets (VLCDs) in type 2 diabetes.
Diabetes Research and Clinical Practice, 85(3), pp.235–242.
16
Wing, R.R., 1991. Effects of a Very-Low-Calorie Diet on
Long-term Glycemic Control in Obese Type 2 Diabetic Subjects.
Archives of Internal Medicine, 151(7), p.1334.
11
7
18 13
10
Importance of weight management in type 2 diabetes: review
with meta-analysis of clinical studies. Anderson et al. Journal of
the American College of Nutrition, Vol. 22, No. 5, 331–339 (2003).
Diabetes Care. Executive summary 2013.
17
Type 2 Diabetes & OPTIFAST® VLCD™
Recommendations for management:
Use of OPTIFAST® VLCD™ Intensive Phase is often
initiated prior to bariatric surgery in obese T2DM patients
(as well as those without T2DM) to reduce the liver size
and so improve accessibility and visibility for laparoscopic
procedures. It is likely that other metabolic markers
improve preoperatively with OPTIFAST® VLCD™ and may
assist with reduction of perioperative complications.
uu
Obese or overweight patients with poor glycaemic control
may benefit from OPTIFAST® VLCD™ as a result of improved
insulin sensitivity (due to weight loss) and possibly ‘islet cell
rest’, resulting in improved endogenous insulin production
and action so that patients may achieve target glucose levels
alone or in conjunction with other hypoglycaemic agents.
uu
Many patients are reluctant to initiate insulin management
despite having high blood glucose. If OPTIFAST® VLCD™
Intensive Phase is used in this setting a considerable
improvement in glycaemic control usually occurs within
1-2 weeks. If not, other hypoglycaemic measures should
be instituted. Thus, patients with poor glycaemic control
who are starting a full OPTIFAST® VLCD™ Program should
monitor their blood glucose levels regularly and be reviewed
within 1-2 weeks of initiating OPTIFAST® VLCD™.
uu
Obese patients with T2DM and associated diabetic
complications such as microalbuminuria, nonproliferative
retinopathy, obstructive sleep apnoea, non-alcoholic fatty
liver disease and diastolic cardiac dysfunction are suitable
for OPTIFAST® VLCD™ management.
uu
Obese patients with more severe complications such
as proteinuria>1g/d, eGFR <60 or risk of fluid balance
complications need to be carefully monitored (creatinine,
eGFR, electrolytes, nutritional markers, nitrogen balance)
if considered for VLCD management.
uu
The initial approach is to use an Intensive Phase to induce
weight loss to a predetermined target. In terms of glycaemic
control, 5-10% weight loss may provide significant benefits.
uu
Patients on insulin or sulphonylureas need to be careful
to avoid hypoglycaemia and if possible, simplifying the
insulin regimen or changing to an oral agent that does
not increase basal insulin secretion would be preferable.
uu
Unless glycaemic control has been poor, the insulin
or sulphonylurea dose should usually be reduced on
commencement of a VLCD and glucose levels should
be closely monitored.
uu
On the full VLCD, patients on basal bolus insulin usually
do not need pre meal insulin bolus doses and require a
reduction in the basal dose. A practical recommendation
is to initially halve the dose and review frequently with self
blood glucose monitoring. When only 1 or 2 meals are
replaced with OPTIFAST® VLCD,™ the bolus dose may only
need to be reduced or withheld prior to these meals.
uu
Patients on twice daily mixed insulin (breakfast and dinner)
who are starting the Intensive Phase of the OPTIFAST®
VLCD™ Program are often best managed by changing
their insulin regimen to a single basal insulin injection
at half the dose of their usual total insulin dose.
uu
Antihypertensive treatment may need to be adjusted
while on a VLCD as often the blood pressure falls.
Thus in these patients blood pressure should be
regularly monitored. Lipids often improve markedly
following weight loss so it may be possible to reduce
doses of lipid lowering medications following a VLCD.
uu
VLCD is not recommended in diabetes with normal
or low weight, or diabetes associated with pregnancy
or cystic fibrosis related diabetes.
uu
OPTIFAST® VLCD™ Guidelines for Diabetes
8
Type 2 Diabetes & OPTIFAST® VLCD™
Case study
Erica has had T2DM for 7 years with associated
obesity, complicated by hypertension, dyslipidaemia,
macroalbuminuria (0.6g/d) with stage III chronic kidney
disease (eGFR around 55ml/min/1.73m2) and sleep apnoea
(on CPAP). She is on metformin, a sulphonylurea, maximum
dose ACE-Inhibitor, a calcium channel blocker and a statin.
Six months ago her HbA1c was 9% and she was
commenced on twice daily mixed insulin. She is now
on 60 units BD. Her HbA1c has improved to 7.6% but she
has gained 10 kg and her BMI is now 40kg/m2. She has
now developed gastro oesophageal reflux and is finding
physical activity very difficult largely because of her weight.
She decides to go on OPTIFAST® VLCD™. In anticipation of
a fall in her glucose levels she is changed to a basal insulin
at a dose of 30 units nocte, and is able to achieve target
blood glucose readings. With increasing weight reduction,
her glucose levels start to fall to 4-5 mmol/L and her insulin
dose is progressively reduced so that by the time she has
been on the VLCD for 6 weeks she is no longer requiring
any insulin. Her blood pressure also falls and she stops
the calcium channel blocker.
9
OPTIFAST® VLCD™ Guidelines for Diabetes
After having been on the VLCD for 3 months she starts
having 1 regular healthy evening meal and replaces
breakfast and lunch with an OPTIFAST® VLCD™ meal.
She gradually weans off the OPTIFAST® VLCD™ products
over the next month and is extremely happy with her
progress. She has managed to reduce her weight by
14 kg so that her BMI is now 35kg/m2. She no longer
requires insulin and her dose of sulphonylurea has been
halved. Her ability to exercise is much improved and she
is intent on maintaining her weight by walking regularly
and eating a healthier diet. She realises that she will need
to monitor her weight regularly and if she finds it increasing,
she would consider recommencing OPTIFAST® VLCD™
either to replace all meals or 1-2 meals daily.
Medications used in
Type 2 Diabetes
Table 1: Medications used in Type 2 Diabetes - considerations and potential benefits with the OPTIFAST® VLCD™ Program.
Medication
Effect on weight
Important considerations
with OPTIFAST® VLCD™
Potential benefits with
OPTIFAST® VLCD™
NON INSULIN AGENTS
Metformin
Modest loss or neutral.
Monitor renal function –
cease if eGFR <50 or unstable
renal function.
May allow control
of glycaemia.
Sulphonylureas
Increases.
Risk of hypoglycaemia
if dose not adjusted.
May allow control
of glycaemia.
Increases insulin
secretion (obesogenic).
Glitazones
Increases.
VLCD may potentiate the risk of
reduction in bone mineral density
with this agent.
May allow control
of glycaemia.
Acarbose
Modest loss or neutral.
Unlikely to be additional benefit
due to low carbohydrate intake
on VLCD.
May be of benefit in
non-replacement meals
or maintenance phases.
DPP-IV Inhibitors
Modest loss or neutral.
May exacerbate gastrointestinal
discomfort. Avoid if patient at
high risk of pancreatitis.
May assist with
adherence to VLCD.
GLP-1 Analogues
Moderate loss.
May exacerbate gastrointestinal
discomfort. Avoid if patient at
high risk of pancreatitis.
May assist with
adherence to VLCD.
INSULIN AGENTS
Basal
Increases.
Risk of hypoglycaemia.
Reduction in dose more likely
if on Intensive Phase.
May allow control
of glycaemia.
Mixed Insulin
Increases.
Risk of hypoglycaemia.
Reduce dose if taken with time
of supplement.
Use of supplement at non
insulin meal may allow better
glycaemic control.
Basal Bolus
Increases.
Risk of hypoglycaemia.
Usually a reduction in dose
of both basal and bolus
component is required.
May allow control
of glycaemia.
OPTIFAST® VLCD™ Guidelines for Diabetes
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OPTIFAST® VLCD™ is a food for special medical purposes for the dietary management of obesity.
Must be used under medical supervision.
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