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MEDICINE DIGEST

VERY-LOW-ENERGY DIETS

WHAT PARTICIPANTS SAY ABOUT DIETING TO ACHIEVE REMISSION

42 DIABETES U P D AT E SPRING 2018

42-46_MedicineDigest_SA4.indd 42 22/02/2018 13:58 THINKSTOCK

PHOTOS: ▲ 22/02/2018 13:58 43

ndings SPRING 2018

E DIABETES UPDAT their and asked to record The participants also attended the Exploring experiences of the VLED This new study is based on semi- interviews with structured participants, carried out before and after the eight-week VLED. Only those who achieved their goals – generally 2.8 per cent body weight loss at week 1 and 8 per cent at week 8 – permitted to continue in were At the end of the VLED the study. phase, the participants’ weight had 98.0 (±2.6)kg to 83.8 fallen from 12 of the 30 (±2.4)kg. Furthermore, of participants achieved remission 2 diabetes (fasting plasma their Type <7mmol/l). Counterbalance The Counterbalance study consisted on an eight-week VLED, followed by a two-week stepped return to a calorie- . It involved 30 adults with ontrolled 2 diabetes of duration 0.5 to 23 Type years. The diet allowed 800kcal per day, of which 600kcal was in the form of liquid formula soups and shakes. The calorie allowance was made of the rest up of , and participants were asked not to drink alcohol. In addition, all oral hypoglycaemic agents were stopped for the duration of the study. at weeks Magnetic Resonance Centre 1, 4 and 8 for biomedical measurements and interviews about their experience of one-to-one support, Weekly the study. was provided to maximise adherence, by email, phone and face-to-face contact. Changes in body mass, plasma used to ketones and diaries were Participants were monitor adherence. also post- blood glucose levels three times a week. part of ndings are rst qualitative study to eight loss achieved very-low- a through energy diet (VLED) can normalise blood glucose levels in people

it examines perceived cally, cacy of the VLED in diabetes

been few studies, have There Specifi studies diabetes remission of future to optimise the outcomes could be used The fi restricted. calorie intake is severely situation where success in a and low- showed that very-low-energy and DiRECT trials The Counterbalance is it like being 2 diabetes. But what of Type lead to remission energy diets can to barriers and facilitators the trials? A new study explores on one of these a review 2 diabetes. Moreover, with Type of the evidence shows that VLEDs are weight loss than associated with greater low-energy diets, minimal interventions six and at three care or standard months. Although VLEDs may seem actually challenging, attrition rates are similar to those for other weight loss in recent and have improved regimens years. Attrition rates can be used as a how acceptable a weight of measure loss plan is to the participant. on the acceptability of VLEDs however, quality of life. in terms of improved been one study looking at has There in a the experience of a VLED delivered which showed that social setting group support, participation in a research in wellbeing study and improvements Now, contributed to weight reduction. at researchers from a new study, takes an in-depth Newcastle University, look at participant experience of VLEDs. barriers to, and facilitators of, adherence and the various behaviour regulation of strategies employed by a group 2 diabetes taking part people with Type of the in a trial of a VLED for remission condition. The new fi which is a the Counterbalance study, trial conducted in the UK single-centre with the aim of achieving normalisation of blood glucose levels (also known as insulin secretion diabetes remission), of liver and and action and reductions application of a through pancreatic VLED. This is the fi look at the acceptability and experience of VLEDs in the context of diabetes It complements the evidence remission. on the effi that has emerged from remission the main Counterbalance study. W 42-46_MedicineDigest_SA4.indd 43 MEDICINE DIGEST

VERY-LOW-ENERGY DIETS

What I found be healthy enough to take care of, and tended to increase the desire to ‘give in’ spend time with, family later in life. to temptation. But awareness and with the diet is that weighing up of the pros and cons the regimen suits "The main thing that I’m after strengthened resolve. Impulse, triggered me. I like to know is trying to cut myself free from by the sight or smell of food, as well diabetes. That’s a very strong as a conscious decision to ‘break’ the what I’m going motivation, because I am not diet led to deviations. It was when to have to eat getting any younger..." the participant was alone that such Woman, 35 years, diabetes deviations were most likely to occur, duration 1.5 years Then there was the wish to get rid of underlining the importance of social the practicalities of managing diabetes, pressure and support. such as the need to take tablets and side effects associated with diabetes Facilitators The interviews included open-ended medication. of adherence questions about participants’ Participants thought about potential The study revealed that the three main experience of the VLED. These were barriers before they began on the VLED. factors facilitating adherence to a VLED conducted face-to-face and audio- Some worried that stressful situations were: rapid results, social support and recorded, with fi eld notes being taken might lead to lapses. Availability of social being involved in a research study. before and after the interview. The support during the study was seen as Weight loss led to being able to fi t into interviewer was a health psychology important – participants could approve smaller clothes and improvements in PhD student, with a Masters in health appearance and wellbeing, all of which psychology, supervised during the provided extra motivation to continue. study by an experienced academic Receiving compliments was a very clinical psychologist. The interviews important form of social support. were anonymised and transcribed Relatives and friends also helped verbatim. adherence through: The analysis of the interview • altering their own behaviour data aimed to: • eating at different times from • understand barriers and the participant facilitators to completing a • refraining from offering food VLED within a clinical study • warning the participant before • understand how intervention cooking, so they could avoid procedures can be optimised tempting sights and smells to maximise acceptability • reminding participants of the of the VLED ‘rules’. • enable more individuals with to succeed with It was particularly helpful to get support dietary remission in the future. from a friend or relative who had successfully gone through a weight loss A thematic approach to the data programme. So was creating a support analysis was used, with coding of system with others who were losing predefi ned theory-based themes, and weight at the same time. Another inclusion of additional themes emerging or disapprove and study staff could element was the feeling of being from the data. offer information and encouragement, privileged by being in the study, for it as well as feedback in terms of weight involved only a small number of people. Motivation and initial and blood glucose measurement. Not wanting to let the researchers expectations down, appreciating the time and effort The main motives for taking part in The VLED experience involved on their part and wanting to Counterbalance were the prospect Although some participants had worried contribute to diabetes research were of diabetes remission and weight loss. that they would feel hungry on the diet, all powerful drivers of adherence. Many participants had previously tried adhering to it turned out to be easier to lose weight and maintain the loss, than anticipated. "I do recognise...that this is a with varying degrees of success. The medical study so I’m one of a prospect of large and rapid weight "I thought I would have been hungry handful of people that are lucky loss in Counterbalance was appealing. from the moment I opened my eyes to actually be on it..." People wanted to dress better and to the moment I closed my eyes " feel more confi dent in their bodies. but I wasn’t" Behaviour regulation Improvements in long-term health and The researchers learned about the regaining control over their health were The most important factors affecting behaviour regulation strategies also a big draw. The wish to increase adherence were physical and social employed to facilitate their adherence to THINKSTOCK the length and quality of life with environments, emotional states and the the diet. These centred around planning, increasing age was another motivating possession of self-regulatory skills. For avoiding and distraction. Some of these

PHOTOS: factor. Many said how they wanted to instance, sadness, loneliness and stress strategies are listed in the following table.

44 DIABETES U P D AT E SPRING 2018

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c trigger ection in ... tter among cantly reduced It was fairly hard work Previous few. Lapses were Registry Control The National Weight consequences of the condition or trying Social support was to conceive a baby. seen as very important and was able to and emotional override environmental triggers that might have led to a lapse. Thus, this aspect should be emphasised trials. remission diabetes in future has shown that subjective feelings of signifi appetite are people without diabetes on a VLED because of the induction of ketones, and associated changes in appetite hormones. This might explain the low lack number of lapses and reported study. of noted in the present in the USA states that 83 per cent of its members experience a specifi participants were In this study, a mirror. 2 motivated by the shock of a Type diabetes diagnosis, fear of the for their weight loss, which could be a highest- reaching medical reasons, ever weight or seeing their refl to start with but it got easier as the weeks went on and then when I started getting a bit fi I could walk further and stand up and sit down and dig the garden. It’s great now. I feel great. Man, 44 years, diabetes duration 2.5 years

SPRING 2018 DIABETES UPDATE the new rst couple of days on behaviour strategies, as Various The main motivators for taking part In conclusion, the VLED for diabetes was both acceptable and remission to than participants had easier to adhere mentioned Barriers to adherence feared. and emotional distress included hunger, triggers, but these proved environmental Rapid minimally disruptive in reality. outcomes, social support, and being involved in a study aided adherence. used to deal with listed above, were The taste and barriers to adherence. of the VLED, with its soups, structure shakes and vegetables, was generally well accepted, though participants made suggestions for introducing They also wanted variety. greater opportunities to meet other to more participants for support. the in the Counterbalance study were and of diabetes remission prospect to issues relating weight loss. However, quality of life and overall health, family, important appearance were improved has underlined research too. Previous the importance of improved and health in successful weight loss. Discussion anyone could follow it "Well, not a lot of food because there’s and not a lot to do with it" The fi the most challenging, but were regimen weeks turned the initial two to three out to be easier than expected when it came to feeling hungry and getting used to the VLED. At the midway point, participants with the lack getting bored did report of variability and solid food that the diet this entailed. Most people overcame feeling by putting the eight-week time period into perspective, and focusing on the potential long-term health gains.

tness, Strategy starting the VLED up leftovers before away/giving away/eating Throwing snacking to avoid food ads or Television, of food Social events with abundance of apple) to hand pieces Having healthy nibbles (carrots, Carrying a bottle of water palatability hot or very cold to improve Drinking the VLED shakes Going to bed earlier or hobbies food with gardening oneself from Getting active/distracting success Reminding oneself of one’s to gain support weight loss attempts others about one’s Telling and understanding tips with experience and Getting a weight loss ‘buddy’ to share while on the VLED, or irritable and achievement dence, control Participants also became more too, with Fitness levels improved of… Avoidance Planning Hunger management Social Theme Food removal Acceptability of the VLED soups and The Minimal easy to prepare. shakes are shopping, into input is required or making decisions about preparing appealed food. This simplicity really to participants. Changes in physical and psychological wellbeing in blood improvements loss, Weight glucose and physical fi others and a sense compliments from of confi all contributed to participants’ overall wellbeing and happiness. improvement "I feel better inside, not just looking better on the outside...I just feel how ill, and that’s feel I don’t I felt before" While they had expected to feel grumpy that their mood participants reported stable. actually remained sensitive to the feeling of hunger and learned how their bodies responded and how to food, and food restriction, they behaved when tempted. All of this helped them to a better understanding with food. While of their relationship because initially, energy levels dropped, they increased of the , gradually over the eight-week trial. the ability to do activities for longer level and at a greater than previously The participants found they of intensity. could also function better in daily life walking, climbing stairs, – with more and playing working in the garden with grandchildren. to a VLED Strategies facilitating adherence 42-46_MedicineDigest_SA4.indd 45 MEDICINE DIGEST

VERY-LOW-ENERGY DIETS

My cholesterol social support. Other studies have resources and less motivated shown that social support has signifi cant individuals. However, the fi ndings of the has come down benefi t in diabetes control and weight current study dispel concerns about the from around 7 to loss. Finally, regular monitoring and acceptability of VLEDs under clinical 3.3 so my nurse has feedback from study staff were also supervision and highlight opportunities powerful facilitators for success on to further optimise support during taken me off my the VLED. Other research has shown dietary diabetes remission. statins. She said my that individuals who weigh themselves blood sugar is now lose more weight, and consume fewer This is a digested version of calories, than those who do not Rehackova L, Araujo-Soares V, that of a normal monitor their weight. Adamson AJ et al (2017). person, not a In conclusion, the current study Acceptability of a very-low-energy shows encouragingly high levels of diet in Type 2 diabetes: patient diabetic. In six adherence to a VLED and provides experience and behaviour regulation months, I’ve lost valuable insights into how the Diabetic Medicine 34 (11); 1554– 3 stone 2 pounds. participants achieved their success. 1567. To download this paper, go It should be kept in mind, however, that to http://onlinelibrary.wiley.com/ My nurse was over less favourable outcomes might occur doi/10.1111/dme.13426 the moon! in a primary care setting, with fewer Woman 47 years, diabetes duration 2.5 years

A further factor in the success rates in this study was that half of the THINKSTOCK participants reported having a ‘buddy’ either inside or outside the trial, who

PHOTOS: could provide them with individualised

DON’T MISS IN THE THE NEXT ISSUE NEXT ISSUE Available OF UPDATE 14/06/2018 URBAN AND GLOBAL DIABETES SPECIAL ● Cities Changing Diabetes – focus on Leicester ● Diabetes in India

Also ● Improving Inpatient Care coming in the ● up The NHS Diabetes Summer issue Prevention Programme

NEXT ISSUE OUT 14 JUNE 2018

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