replacement programme 1000

Information for patients Dietetics - Diabetes

PROUD TO MAKE A DIFFERENCE SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST The meal replacement programme is a programme suitable for people with diabetes for whom weight loss is crucial for health reasons. Research has found that with substantial weight loss (15kg or more), 9 out of 10 people can achieve remission of Type 2 diabetes. Diabetes remission is when you have an HbA1c of less than 42mmol/mol without any diabetes medication. This is most likely to occur if you have had diabetes for less than 6 years. If you are aiming for remission, you should aim to lose 15kg (2 stone, 7 pounds). It doesn’t matter how long this takes. However, research has found that a strict such as the meal replacement programme is an effective way of achieving this more quickly.

There are two stages to the programme:

Stage 1: Meal replacement This first stage is followed for 8 to 12 weeks. During this time only meal replacement shakes, and a limited amount of milk, fruit and vegetables are included. No other (such as potatoes, bread, rice, pasta, meat, poultry or fish) are allowed. You will be in regular contact with your diabetes and if you are on diabetes or blood pressure medications, you should be monitored by your Diabetes Specialist Nurse and GP. It is essential that you do not undertake the diet without this supervision.

Stage 2: reintroduction After around 8 to 12 weeks, you will move on to stage 2 which involves a planned reintroduction of . Long term support will be essential to help avoid weight re-gain.

page 2 of 24 Stage 1: What can I eat and ? The meal replacement programme is made up of the following: • 3 meal replacement milkshakes (for example Slimfast, Asda Great Shape, Tesco Ultraslim, etc). • 2 servings of salad or cooked vegetables (excluding potatoes) (approx 100 kcals per serving). • 2 small portions of fresh fruit (50 kcals each). Each portion should be no bigger than a tennis ball sized portion. • ½ pint (300ml) skimmed milk (100 kcals). • Calorie-free . In addition to your usual drinks, have an extra 1 litre (2 pints) of fluid a day. Calorie-free drinks include: water, herbal , black tea, black coffee, diet soft drinks, sugar free squashes (less than 7 kcals per serving). If you do not drink enough fluid you may experience headaches. • If desired: sugar free jelly - no more than one sachet (11-28 grams or 1 pint) per day and sugar free mints or chewing gum.

page 3 of 24 Suggested meal plan It is recommended that you spread the meal replacements out evenly over the day, leaving at least four to five hours between each shake. If you are using powdered shakes, make them up at each meal time so that they are fresh each time.

Breakfast: • 1 meal replacement • Tea or coffee with skimmed milk from allowance

Mid-morning: • 1 portion of fresh fruit • Tea / coffee or low calorie drink

Lunch: • 1 meal replacement • Serving of salad / vegetables

Mid-afternoon: • 1 portion fresh fruit

Evening meal: • 1 meal replacement • Serving of vegetables / salad

page 4 of 24 Stage 1 : Tips for enjoying meal replacements • Shakes taste better served cold • Add extra ice to the shakes to increase volume • You can add extra flavourings for more variety e.g. – Add orange, mint, coffee essence to the shakes – Add herb and spice mixes to the soups

Stage 1 : Tips for enjoying vegetable meals • You can have two vegetable meals a day, for example homemade soup or salad at lunchtime and stir fry or roasted vegetables in the evening. Later in the booklet there are some recipe ideas. • The portion of vegetables is around two good handfuls of vegetables at each of the two meals. • Try to include some green leafy vegetables each day such as cabbage, broccoli, lettuce and other salad leaves, spinach etc. • Steam, microwave or roast vegetables instead of boiling them, to keep in the goodness. • Other vegetables to include: onions, beansprouts, carrot, squash, peppers, radish, water chestnuts, aubergine, celery, tomatoes, okra, peas, cauliflower, green beans, courgette, sprouts, leeks, mushrooms, turnip, fennel, artichoke, asparagus. • Avoid potato, sweet potato, yam, parsnip, avocado, olives, sweetcorn, nuts, seeds, pulses, coleslaw, potato salad, etc. • Add flavour using herbs, spices and low calorie sauces, for example: lemon/lime juice, vinegar, soy sauce, fresh garlic and ginger, fresh or dried herbs, chilli, spices such as pepper, curry powder, peri peri seasoning, Chinese five spice. • A small amount of fat adds flavour and helps the absorption of . Keep to one teaspoon a day of olive oil or mayonnaise or butter or rapeseed oil.

page 5 of 24 It sounds very strict; how will I cope? It is best not to start the diet if there are special events coming up e.g. a holiday, Christmas or a birthday. Plan to start it when you know the 12 weeks are relatively free of social occasions or other important events. As well as support from your dietitian, it is helpful to have support from family and friends, especially if you are usually responsible for at home. Although the diet is very strict, most people have found that after a few days they do not feel excessively hungry any more. Much of our can be for reasons other than , for example boredom or comfort. It is important to think of ways to avoid this from happening. You could try the following: • Plan some alternative activities to distract yourself from thoughts of eating e.g. gardening, ringing a friend, going for a walk, tidying up, having a bath. • Get support from family and friends so they can encourage you if you are struggling. • Write down your reasons for wanting to lose weight and how it will benefit you. Pin them up somewhere where you can see them or read them regularly to remind yourself of your motivations. • Reward your successes. Treat yourself to a trip to the cinema, a magazine, CD, or book. Buy yourself a bunch of flowers. • Record your progress. You may want to write down your weekly weight or waist measurement or note whether an item of clothing is becoming looser. Recording your achievements can help motivate you to continue.

page 6 of 24 While following the diet you may experience some of the following:

Dizziness: This may occur during the first few days. Be careful to get up slowly from sitting or lying down. If you take tablets for high blood pressure and you are experiencing frequent dizziness, get your blood pressure checked. Contact your practice nurse for this.

Constipation: you are drinking plenty of fluids and eating the recommended portions of fruit, vegetables and salad. Activity such as walking may help. Consider an over the counter laxative such as fybogel or senna if necessary.

Frequent urination: You may find you are passing urine more frequently. Make sure you are drinking plenty and stay well hydrated. If your urine is dark in colour you need to increase your fluid intake.

Bad breath: Bad breath can occur when your body is burning up fat for fuel which is normal on this diet. You may find it useful to use a mouthwash.

Tiredness: You may be more tired, particularly in the first few days of starting the diet. This will improve with time.

Risk of hypos: Ring us if your blood sugar levels are less than 5 mmol/L. We will advise you on reducing your insulin or tablets. Too much insulin or treating frequent hypos will make it harder to lose weight.

page 7 of 24 Managing your diabetes on the meal replacement programme Diabetes medications When you start the diet you will be significantly reducing your food intake and will start to lose weight. For both these reasons you are likely to need less diabetes medication. You may be advised to stop or reduce diabetes tablets that can cause hypos, such as gliclazide tablets and insulin injections. These may be further reduced as blood glucose falls. If blood glucose remains high, or rises, your medication will be re-introduced. It is important that you get advice on adjusting your diabetes medication by contacting your Diabetes Nurse Specialist or GP before you start. They will advise what changes are required. Monitoring your blood glucose levels for hypos (you will be advised if this section is relevant for you) If you are on insulin or gliclazide then you are at risk of having a hypo, where your blood glucose level goes too low (less than 4mmol/L). Frequent hypos are unpleasant and will also mean you having to take in more calories than you plan to. It is therefore important to: • Check your blood sugars regularly, before each meal replacement product or meal and before bed. • When you attend your appointments or have a telephone consultation, have your blood glucose readings to hand. These will be reviewed and further medication changes will be advised as necessary. If driving, do additional checks and remember by law your blood glucose must be above 5mmol/L at all times, before and whilst driving a vehicle. You should not be having any more than one hypo a week. If you are or have any concerns, please contact your diabetes team. Hypos are generally a sign that your doses of insulin or tablets are too high and

page 8 of 24 need reducing. If your doses of insulin are higher than necessary then this will make it harder for you to lose weight. Your dietitian will discuss how to treat hypos with you, if appropriate, and provide you with a leaflet explaining this entitled 'Hypoglycaemia'. Other medications Losing significant amounts of weight may mean that you need a smaller dose of other medications. If you take tablets for high blood pressure you should have your blood pressure checked once a month by either your GP or practice nurse, or at the diabetes centre. You may need your medications reducing as you lose weight. If you take anti-coagulants (blood thinning tablets) such as warfarin you should have your INR monitored more frequently. You should tell your GP or the anticoagulant clinic that you are starting the MRP.

page 9 of 24 What happens after 12 weeks on the meal replacement programme? After 8 to 12 weeks on meal replacements you will now move on to Stage 2: Food reintroduction. This will be carried out with the support and guidance of a dietitian. You will start to gradually reintroduce meals. Depending on whether you are aiming to lose weight or to maintain your weight at this stage, you will be provided with some different options for this. Activity Being more active can help with weight loss. It can be difficult to be active during Stage 1, due to the strict , however if you do feel able to exercise, then you should do so. Research shows that people who are active find it easier to maintain weight loss. Therefore it is important to think about how you will increase your activity levels once you reach Stage 2. During and after Stage 2, it is recommended that you build your activity levels up to: • 30 minutes of moderate activity five times a week. Moderate activity means any activity that leaves you feeling warm and breathing more heavily than usual. This could be; brisk walking, gardening, aerobics or dance classes, swimming, cycling, or other sports such as badminton. • If 30 minutes in one go seems like too much to start with, split it into smaller bouts, for example try 3 x 10 minutes or 2 x 15 minutes, gradually building up to 30 minutes of continuous exercise. Being more active will also help to keep the weight off. Take any opportunity you can to stand more and sit less. Add in extra steps whenever you can, for example taking a longer way round to the bus stop. A few extra steps here and there in a day will add up to make a big difference to your wellbeing.

page 10 of 24 Recipe ideas Carrot and Coriander Soup (6 servings)

Ingredients • 1 spray of cooking spray • 1.2 litres vegetable stock • 1kg carrots, peeled and • Large bunch of fresh coriander, chopped chopped • Large onion, sliced thinly • Salt and pepper

How to

• Stir fry the onion in the low fat cooking spray for around 5 minutes. • Add the carrots, stock and seasoning and simmer for 15 minutes until the carrots are tender. • Add the coriander, liquidise and serve. Stir Fry Vegetables (2 servings)

Ingredients • 100g bean sprouts • 1 garlic clove, crushed • ½ teaspoon of five spice • 1 red pepper, cut into thin strips powder • 1 yellow pepper, cut into • 100g mushrooms, cut in thin thin strips strips • 1 carrot, cut into thin strips • 1 spring onion, cut in thin strips • 50g green beans • 1 spray of cooking spray • 2 teaspoons soy sauce

How to cook • Stir fry all the vegetables and five spice for 5 minutes in a wok using the low fat cooking spray. • Add the soy sauce and serve.

page 11 of 24 Roast Courgettes and Pepper (2 servings) Ingredients • 3 small courgettes, sliced lengthways • 1 yellow pepper, sliced • 1 onion, sliced • 1 teaspoon crushed rosemary leaves • 1 teaspoon chopped parsley • Black pepper to taste • 1 spray of cooking spray How to cook • Place vegetables and herbs on a baking tray and spray them with the low fat cooking spray. • Roast for 30 minutes at 230°C / 450°F / Gas Mark 8.

Garden Vegetable Soup (3 servings) • 1 spray of cooking spray • 1 small onion, diced • 2 garlic cloves, minced • 800ml vegetable stock • ½ small green cabbage, shredded • 100g green beans • 2 carrots, diced • 1 tablespoon tomato puree • ½ teaspoon dried basil • ¼ teaspoon dried oregano • ¼ teaspoon salt • ½ courgette, diced

page 12 of 24 How to cook • Spray a large saucepan with the low fat cooking spray. • Sauté the carrot, onion and garlic over a low heat until softened, about 5 minutes. • Add the stock, cabbage, beans, tomato puree, basil, oregano and salt; bring to a boil. • Reduce heat; simmer, covered for 15 minutes (until beans are tender). • Stir in the courgette and heat for 3-4 minutes. Serve hot.

Oven Roasted Carrots with Garlic (1 serving) • 230g carrots, chopped in half lengthways • 1 garlic clove, crushed • 1 teaspoon coriander seeds, crushed • Black pepper to taste • 1 spray cooking spray How to cook • Put the ingredients on a baking tray and spray with the low fat cooking spray. • Roast the carrots in the oven at 230°C / 450°F / Gas Mark 8 for 30-40 minutes.

page 13 of 24 Chilli Soup (4 servings) • 2-3 fresh chillies, deseeded and finely chopped • 150g green beans, chopped into 3 • 150g broccoli, broken into florets • 150g dark green cabbage, shredded • 1 onion, chopped • 2 garlic cloves, crushed • 850ml vegetable stock • Salt and pepper How to cook • Place all the ingredients in a pot and cook for 15-20 minutes until soft. • Liquidise the soup and season to taste.

Braised Celery (4 servings) • ½ head of celery, trimmed and cut into 3 pieces • 1 medium onion, thinly sliced • 1 carrot, peeled and thinly sliced • 225ml vegetable or chicken stock • 1 tablespoon chopped parsley How to cook • Put all the ingredients, except the parsley, into a saucepan and simmer for 30 minutes. • Serve with parsley sprinkled on top.

page 14 of 24 Spinach Soup (5 servings) • 1 onion, finely sliced • 1 leek, finely sliced • 1 litre vegetable stock • ¼ teaspoon dried marjoram • ¼ teaspoon dried thyme • 1 bay leaf • 400g baby spinach, washed • ¼ teaspoon ground nutmeg • Salt and pepper How to cook • Cook the onion, leek, marjoram, thyme, and bay leaf in the stock for about 15 minutes, until onions and leeks are soft. • Remove the bay leaf and add the spinach, cook for 3-4 minutes until wilted. • Liquidise the soup and season to taste before serving.

Vegetable Curry (4 servings) • 1 spray of cooking spray • 1 onion, finely chopped • 1 tablespoon curry powder (use less for a milder flavour) • 1 garlic clove, crushed • 100g cauliflower florets • 2 carrots, sliced • 1 courgette, sliced • 100g mushrooms, sliced • 1 red pepper, chopped • 100g broccoli

page 15 of 24 • 400g tinned tomatoes • 500ml vegetable stock • 1 tablespoon tomato puree • Salt and pepper How to cook • Sauté the onions, garlic and curry powder in the low fat cooking spray for 3 minutes. • Add the carrots and cauliflower and cook for a further 2 minutes. • Add the remaining ingredients, bring to the boil and simmer for 25 minutes until all the vegetables are tender. Season to taste.

Roasted Tomato and Red Onion Soup (4 servings) • 450g ripe tomatoes • 2 red onions, sliced • ½ a pack fresh sage • 2 sprays of cooking spray • 1½ litres vegetable stock • Salt and pepper How to cook • Preheat the oven to 200°C / 390°F / Gas Mark 6. • Place the tomatoes and onions in a tray, coat in low fat cooking spray and season well. • Roast for 20 minutes. • Pour over the vegetable stock and roast for a further 20 minutes then liquidise and serve.

page 16 of 24 Cucumber and Mushroom Soup (3 servings) • 1 medium cucumber, split in half and cut into thin slices • 200g mushrooms, sliced • 600ml vegetable stock • Salt • 2 teaspoons light soy sauce • Finely chopped salad onions to How to cook • Bring the stock back to the boil. • Add the mushrooms and salt and simmer for 1 minute. • Add the cucumber and soy sauce and simmer for a further minute. Serve hot.

Allspice Green Beans (2 servings) • 1 spray of cooking spray • 2 garlic cloves, crushed • 500g fresh green beans, trimmed and snapped • 110ml water • 1 dessertspoon ground allspice • Salt and pepper How to cook • Spray a saucepan with the low fat cooking spray and heat up over a medium heat. • Add the garlic and cook until lightly browned, stirring frequently. • Mix in the green beans and water and bring to a boil. • Stir in the allspice, salt and pepper. • Cover and simmer for 20 minute, until the green beans are soft.

page 17 of 24 Tomato Soup (4 servings) • 1 spray of cooking spray • 2 x 440g tins chopped tomatoes • 2 yellow peppers, deseeded • 3 teaspoons dried mixed herbs • 50g mushrooms, chopped • 1 onion, chopped into small chunks • 1 garlic clove, crushed • 500ml vegetable stock • Salt and pepper How to cook • Spray a saucepan with the low fat cooking spray. • Gently cook the onion, pepper, mushrooms and garlic to soften. • Add the remaining ingredients, bring to the boil and simmer for 15 minutes. • For a smooth soup liquidise, for a chunky soup serve straight away.

Roasted Red Vegetables with Ginger and Garlic (3 servings) • 2 sprays cooking spray • 4 plum tomatoes, cut in half • 1 red pepper, deseeded and cut into 8 • 1 red onion, quartered • ½cm root ginger, peeled and chopped • 2 garlic cloves, unpeeled • ½ big sprig of thyme • Salt and pepper

page 18 of 24 How to cook • Preheat the oven to 200°C / 400°F / Gas Mark 6. • Spray the oil into a large oven proof and add the tomatoes, peppers and onions. • Sprinkle with ginger and tuck garlic cloves and thyme among the red vegetables. • Spray some more oil on top and season with the salt and pepper. • Turn the vegetables around so everything is evenly coated. • Roast for about 40-45 minutes, turning occasionally, until tender and patched with brown.

Ratatouille (1 serving) • 1 spray of cooking spray • 1 courgette, sliced diagonally • ½ red onion, peeled and cut into thin wedges (held together by the root) • ½ red or yellow pepper, chopped into medium chunks • ½ small aubergine, halved lengthways and sliced into half moons • 1 garlic clove, roughly chopped • 2 ripe tomatoes, cut into large chunks • Salt and pepper How to cook • Preheat the oven to 220°C / 430°F / Gas Mark 7. • Put all the courgette, onion, pepper, aubergine and garlic into a non-stick roasting pan in 1 layer (can be 1½ layers) and spray with the low fat cooking spray. • Roast for 20 minutes, stirring occasionally, then remove from the oven, stir in the tomatoes then roast for 10 minutes. • Remove from the oven and season to taste.

page 19 of 24 Mushrooms and Pepper in a Tomato Sauce (1 serving) • 1 spray of cooking spray • 1 onion, chopped into chunks • 1 carrot, chopped into chunks • 1 celery stick, chopped into chunks • 2 garlic cloves, crushed • 2 x 200g tinned tomatoes • 100g button mushrooms, quartered • 1 red pepper, chopped into medium pieces • 1 teaspoon mixed herbs (or a mixture of basil, oregano and thyme) • 1 tablespoon tomato puree • Salt and pepper How to cook • Cook the vegetables (except the tomatoes), bay leaf, tomato puree and herbs in a pan using the low fat cooking spray for 10-15 minutes or until the vegetables are tender. • Stir in the chopped tomatoes and 150ml water and simmer gently for 20-25 minutes until it has reduced and is thick (if you want it thicker cook it for longer, and thinner add water). • Season to taste and remove the bay leaf before serving Roasted Pepper, Broccoli and Lemon Salad (1 serving) • 1 spray cooking spray • 50g purple sprouting broccoli, cut into florets • ½ Romero / red pepper, sliced • ½ onion, sliced • 2 garlic cloves, sliced • ½ lime, halved • ½ lemon, halved • Salt and pepper

page 20 of 24 How to cook • Preheat the oven to 200°C / 400°F / Gas Mark 6. • Fry the broccoli, pepper, onion, garlic, lemon and lime for 2 to 3 minutes, stirring frequently, in a large frying pan using the low fat cooking spray. • Season, then roast in the oven for 6-8 minutes or until the vegetables are tender. • Serve, and squeeze the lemon and lime juice over the top. Beetroot Soup • 250g beetroot, peeled and roughly chopped • 140g carrots, peeled and roughly chopped • 2 shallots, roughly chopped • ½ a garlic clove, chopped roughly • ½ stick of celery, roughly chopped • ½ tablespoon caraway seeds • Enough vegetable stock to cover the vegetables with about 150ml pint extra • ½ bay leaf and salt and pepper How to cook • Place the vegetables in a large sauce pan with the bay leaf and caraway seeds. • Cover with the stock, bring to a rapid boil, cover and reduce the heat to a simmer and cook for about 1 hour or until the vegetables are tender. • Remove the bay leaf and liquidise the soup until smooth, season and pass the soup through a medium sieve. • Reheat gently (but do not allow to boil) and serve.

page 21 of 24 Weight record

Starting weight: ______Height: ______BMI: ______

Date Weight Comments

page 22 of 24 Your notes

page 23 of 24 Patient’s name ......

This information has been given to you by ......

Contact number ......

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PD10224-PIL4377 v1 Issue Date: September 2019. Review Date: September 2022