Cost effective solution “meal replacement”

2. Diabetes and obesity
 Obesity is known to be
directly linked to type 2
diabetes mellitus (T2DM)
and, not surprisingly, the
growing prevalence of
diabetes parallels the
increased prevalence of
obesity .
J Clin Invest. 2011;121(6):2076-
2079.
JAMA 2001, 286:1195–1200

3. Obesity and insulin sensetivity
 Modest weight reduction of
about 7% over a 6-month period
through caloric reduction and
increased physical activity
improves insulin sensitivity.[1], [2]
1.DIABETES CARE, VOLUME 26, NUMBER 7, JULY 2003
2. OBESITY RESEARCH Vol. 11 No. 9 September 2003

4. Type of replacement in dietary content
 Meal replacement : a) liquid meal
b) solid meal
 Breakfast replacement

5. Cost effective solution “meal
replacement”
 Multidisciplinary weight management
approaches, including the use of meal
replacements (MRs) within a structured
dietary plan, are emerging as viable and
potentially cost-effective solutions to
overweight and obesity management in
T2DM.
Diabetes, Obesity and Metabolism, 6, 2004, 85–94

6. Structured
Dietary
Plan
Carbohydrate
40%
Fats
30%
Meal high in fiber
content
Eg: vegetables and
fruits with high
fibers.
Protein
30%

7. Structured
Dietary Plan
for Weight
Reduction
40% of intake, with
a total daily intake
of no less than 130
g/d 1. [1], [2]
comprise up to 20% to
30% of daily caloric
intake. [2]
remaining 30% should
come from fat. Trans fats
should be eliminated
saturated fat should be
reduced to 10% or even
7%. [2], [3]
Meal plans should also
focus on increased
soluble fiber (eg, from
fresh fruits and
vegetables) and healthy
carbohydrate
consumption, especially
foods high in fiber and
with a low glycemic index
1. DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008
2. Curr Diab Rep 2006, 6:405– 408.
3. J Am Pharm Assoc 2005,45:492–499

8. Dietary Treatment and Long-Term Weight Loss and Maintenance in Type 2
Diabetes
 Increasing body weight is associated with
increasing risk for glucose intolerance and type 2
diabetes .
 Greater abdominal distribution of weight and
visceral obesity also increase the risk for type 2
diabetes .
 Greater amounts of abdominal obesity is
associated with insulin resistance, which plays a
central role in the metabolic constellation that
includes dyslipidemia, hypertension, and
increased risk of cardiovascular disease, in
addition to type 2 diabetes
 Therefore, weight loss is extremely important to
improve glycemic control and to decrease other
risks associated with diabetes and obesity.
 Short-term weight-loss results in improved
glycemic control in patients with diabetes by
decreasing insulin resistance, decreasing hepatic
glucose production, and possibly increasing
insulin secretion .
Abdominal obesity
Insulin resistance.
OBESITY RESEARCH Vol. 9 Suppl. 4 November 2001

9. MRs for Weight Management in Patients With Diabetes
 Aim: is to investigate the health outcomes and mortality among patients with diabetes
who lose and maintain weight loss for up to 10 years.
 Study design: The 5145 participants of the Look AHEAD study were randomly divided
into two intervention groups: one uses intensive lifestyle intervention (ILI) including
possible use of MRs ; another receives standard diabetes support and education (DSE).
 Observation: The research groups published their first year results that showed
significant weight loss of an average of−8.6% in the ILI group versus−0.7% in the DSE
group [1]. This amount of weight loss resulted in significant improvement in diabete
control (absolute hemoglobin A1c [HbA1c] reduction of −0.64% in the ILI versus−0.14%
in the DSE from a baseline of∼7.3 in both groups [P<0.001]).
 Conclusion: Notably, HbA1c lowering was observed in the context of decreased
glucose-lowering medication use in the ILI group and increased medication use in the
DSE group. These observations were maintained after 4 years of intervention [2]. A
systematic review of 11 other long-term studies with a follow-up of more than 2 years
showed that mortality risk was reduced by 25% in patients with diabetes who
intentionally lost a significant amount of weight .
1.Diabetes Care. 2007 June ; 30(6)
2.JAMA 2001, 286:1195–1200
3.Diabetes, Obesity and Metabolism, 6, 2004, 85–94

10. The UK Prospective Diabetes Study
 Aim: To provide useful information on initial dietary treatment of type 2 diabetes.
 Study structure : In this study, of the initial 3044 newly diagnosed patients with
diabetes, 447 were excluded because of an inability to achieve a fasting blood
glucose level of ,15 mM after 3 months of dietary therapy. Of the remaining 2597
patients (mean body weight, 132 6 26% ideal body weight), mean weight loss was
5 kg over these initial 3 months.
 Observations:
 Four hundred eighty-two patients (16%) achieved a fasting glucose level of ,6 mM
after 3 months of dietary treatment.
 Patients who had higher initial fasting blood glucose levels and patients who lost
more weight experienced the greatest decrease in levels of fasting blood glucose.
 In 823 subjects who continued on dietary treatment, weight 1 year later was
virtually the same as after the first 3 months.
 Conclusion: Greater the initial fasting blood glucose level, the larger the amount
of weight loss that was required.
Metabolism, Vol39, No 9 6eptember). 1990: pp 905-9 12

11. Clinical trials on prepared meal
 Objective To assess the long-term effects of a prepackaged, nutritionally
complete, prepared meal plan compared with a usual-care diet (UCD) on weight
loss and cardiovascular risk factors in overweight and obese persons.
 Design In this randomized multicenter study, 302 persons with hypertension and
dyslipidemia (n = 183) or with type 2 diabetes mellitus (n = 119) were randomized
to the nutrient-fortified prepared meal plan (approximately 22% energy from fat,
58% from carbohydrate, and 20% from protein) or to a macronutrient-equivalent
UCD.
 Main Outcome Measures The primary outcome measure was weight change.
Secondary measures were changes in blood pressure or plasma lipid, lipoprotein,
glucose, or glycosylated hemoglobin levels; quality of life; nutrient intake; and
dietary compliance.
Arch Intern Med. 2000;160:2150–8.

12.  Results After 1 year, weight change in the hypertension/dyslipidemia group was
−5.8 ± 6.8 kg with the prepared meal plan vs −1.7 ± 6.5 kg with the UCD plan
(P<.001); for the type 2 diabetes mellitus group, the change was −3.0 ± 5.4 kg with
the prepared meal plan vs −1.0 ± 3.8 kg with the UCD plan (P<.001) (data given as
mean ± SD). In both groups, both interventions improved blood pressure, total
and low-density lipoprotein cholesterol levels, glycosylated hemoglobin level, and
quality of life (P<.02); in the diabetic group, the glucose level was reduced
(P<.001). Compared with those in the UCD group, participants with
hypertension/dyslipidemia in the prepared meal plan group showed greater
improvements in total (P<.01) and high-density lipoprotein (P<.03) cholesterol
levels, systolic blood pressure (P<.03), and glucose level (P<.03); in participants
with type 2 diabetes mellitus, there were greater improvements in glucose (P =
.046) and glycosylated hemoglobin (P<.02) levels. The prepared meal plan group
also showed greater improvements in quality of life (P<.05) and compliance
(P<.001) than the UCD group.
 Conclusions Long-term dietary interventions induced significant weight loss and
improved cardiovascular risk in high-risk patients. The prepared meal plan
simultaneously provided the simplicity and nutrient composition necessary to
maintain long-term compliance and to reduce cardiovascular risk.
Arch Intern Med. 2000;160:2150–8.

13. Liquid Meal Replacements
Liquid
meal
Type 2
diabetes

14. Liquid Meal Replacements and Glycemic Control in Obese Type
2 Diabetes Patients
 Objective: Although weight management is an important component in
the treatment of type 2 diabetes, there has been concern about the use of
liquid meal replacements (MRs) in treating obese patients with type 2
diabetes because of the sugar content of the MRs. The goal of this study
was to evaluate the safety and feasibility of using MRs for weight loss in
obese patients with type 2 diabetes.
 Research Methods and Procedures: Seventy-five subjects with type 2
diabetes, treated only with oral agents, were recruited for this 12-week
clinical study. Subjects were randomized into three groups using either a
MR containing lactose, fructose, and sucrose, a MR in which fructose and
sucrose were replaced with oligosaccharides (sugar-free Slim-Fast), or an
exchange diet plan (EDP) using the proportion of macronutrients
recommended by the American Diabetes Association.
OBESITY RESEARCH Vol. 9 Suppl. 4 November 2001

15.  Results: Fifty-seven patients (41 MR and 16 EDP) finished the study. None
developed serious adverse effects, including major hypoglycemic
reactions. Weight losses in the MR 1 and MR 2 groups were comparable
(6.4% and 6.7%, respectively) and greater than the weight loss in the EDP
group (4.9%). Fasting glucose level was significantly reduced in the MR
group compared with the EDP group (p 5 0.012). There was a significant
reduction in the MR group in total cholesterol and low-density lipoprotein
cholesterol that was not seen in the EDP group.
 Discussion: We have shown that liquid MRs are a safe and effective
weight loss tool for obese subjects with type 2 diabetes, and can result in
improvements in body weight, glucose, insulin, hemoglobin A1c and lipid
levels.
OBESITY RESEARCH Vol. 9 Suppl. 4 November 2001

16. Breakfast replacement in patients with type 2 diabetes: a randomised
clinical trial
 Objective : To investigate the effect of isoenergetic breakfast replacement by a
low-GR liquid formula.
 Study design :
 a randomised, controlled, cross-over trial At baseline, the subjects recorded their
food intake for 3 d for the determination of average breakfast energy content.
Subsequently, they were assigned to a low-GR or control diet by block
randomisation.
 In the low-GR arm, the subjects consumed a breakfast replacement consisting of
an isoenergetic amount of Glucerna SR (Abbott Nutrition) for 3 months.
 In the control arm, the subjects were allowed to consume a free-choice control
breakfast. No additional dietetic support was provided.
• End-points:
 Primary end-points: were postprandial plasma glucose and insulin excursions in
the clinical setting, postprandial glucose excursions measured using continuous
subcutaneous glucose measurement (CGM) at home, and fasting plasma levels of
glucose and insulin.
British Journal of Nutrition (2014), 112, 504–512

17.  Secondary end-points:were fasting plasma levels of HbA1c and lipids, body
weight and glucose tolerance. In addition, we measured plasma C-reactive protein
concentration, waist circumference, body fat percentage, blood pressure and
intakes of carbohydrates, lipids and protein.
• Results :
 Glucose and insulin levels: During admission to the clinical research unit,
postprandial glucose and insulin excursions were significantly reduced after
ingestion of the low-GR breakfast compared with the isoenergetic control
breakfast.
 Glycated Hb and lipid levels, and glucose tolerance:The 3-month low-GR liquid
meal replacement did not affect fasting HbA1c or lipid levels . At the end of each
3-month dietary period, glucose tolerance was assessed by an OGTT in nineteen
subjects . In one subject, no OGTT was performed due to family issues. Glucose
values 2 h after ingestion of glucose were not found to be different between the
dietary groups (low GR: mean 13·4 (SD 4·1) mmol/l; control: mean 12·6 (SD 4·0)
mmol/l; P¼0·190). However, the AUC of glucose excursions after ingestion of
glucose was slightly lower in the control group than in the low-GR breakfast group
British Journal of Nutrition (2014), 112, 504–512

18.  Discussion: Low-GI diets are known to reduce HbA1c levels in
patients with type 2 diabetes(6). In the present study, we
showed that isoenergetic breakfast replacement with a low-
GR liquid formula reduced postprandial glycaemia compared
with an isoenergetic regular Dutch breakfast under controlled
circumstances in a clinical setting
British Journal of Nutrition (2014), 112, 504–512

19. Weight management using a meal replacement strategy
 OBJECTIVE: Although used by millions of overweight and obese consumers, there
has not been a systematic assessment on the safety and effectiveness of a meal
replacement strategy for weight management. The aim of this study was to
review, by use of a meta- and pooling analysis, the existing literature on the safety
and effectiveness of a partial meal replacement (PMR) plan using one or two
vitamin/mineral fortified meal replacements as well as regular foods for long-term
weight management.
 Design : Randomized, controlled PMR interventions of at least 3 months duration,
with subjects 18 y of age or older and a BMIZ25 kg/m2, were evaluated.uding
meta and pooling analysis.
 Results : Subjects prescribed either the PMR or RCD treatmen plans lost
significant amounts of weight at both the 3-month and 1-year evaluation time
points. All methods of analysis indicated a significantly greater weight loss in
subjects receiving the PMR plan compared to the RCD group. the PMR group lost
B7–8% body weight and the RCD group lost B3–7% body weight. A random effects
meta-analysis estimate indicated a 2.54 kg (Po0.01) and 2.43 kg (P¼0.14) greater
weight loss in the PMR group for the 3-month and 1-y periods, respectively. A
pooling analysis of completers showed a greater weight loss in the PMR group of
2.54 kg (Po0.01) and 2.63 kg (Po0.01) during the same time period.
International Journal of Obesity (2003) 27, 537–549.

20. Meal Replacements for Weight Loss in Type 2 Diabetes
 Background: There is limited information on the effectiveness of meal replacement (MRs)
as a weight-loss strategy in an unsupervised community setting.
 Aim: To evaluate the use of MR compared with a diet book for 6 months.
 Subjects and Methods: Obese subjects (n = 120) with type 2 diabetes mellitus were
recruited from the community in Adelaide, South Australia, and randomised to intervention
or control. Subjects in the intervention were advised to consume 2 MR/day for 3months and
1 MR/day for 3 months and follow the manufacturers’ instructions from printed material and
the website. Subjects in the control arm were given a commercially available diet book.
 Results: Consumption of 2 MR for 3 months and 1 MR for the subsequent 3 months led to
weight loss of 5.5 kg (5%) and a 0.26% decrease in HbA1c while the diet book group had a
weight loss of 3 kg (3%) (P = 0.027 for difference between groups) and a decrease in HbA1c
of 0.15% (between group ns) in those who completed the 6-month study. On intention-to-
treat (last observation carried forward) weight loss at 6 months was 3.4 kg in MR and 1.8 kg
in control (P = 0.07). Decreases in HbA1c were 0.22% and 0.12%, respectively (P = ns). HDL
cholesterol increased by 4% in MR and decreased by 1% in control (P = 0.004). Blood
pressure decreased equally in both groups. There were reductions in fasting glucose in both
groups at 6 months with no changes in LDL-cholesterol or triglyceride concentrations.
 Conclusion: MR confers benefits in HbA1C reduction and weight loss at 6 months in those
who completed the study.
Journal of Nutrition and Metabolism Volume 2012, Article ID 918571, 7 pages

21. Low glycaemic index, or low glycaemic load, diets for diabetes
mellitus
 Objectives:To assess the effects of low glycaemic index, or low glycaemic load, diets
on glycaemic control in people with diabetes.
 Selection criteria: They assessed randomised controlled trials of four weeks or
longer that compared a low glycaemic index, or low glycaemic load, diet with a
higher glycaemic index, or load, or other diet for people with either type 1 or 2
diabetes mellitus, whose diabetes was not already optimally controlled.
 Main results: Eleven relevant randomised controlled trials involving 402
participants were identified. There was a significant decrease in the glycated
haemoglobin A1c (HbA1c) parallel group of trials, the weighted mean difference
(WMD) was -0.5% with a 95% confidence interval (CI) of - 0.9 to -0.1, P = 0.02; and
in the cross-over group of trials the WMD was -0.5% with a 95% CI of -1.0 to -0.1, P
= 0.03. Episodes of hypoglycaemia were significantly fewer with low compared to
high GI diet in one trial (difference of -0.8 episodes per patient per month, P <
0.01), and proportion of participants reporting more than 15 hyperglycaemic
episodes per month was lower for low-GI diet compared to measured carbohydrate
exchange diet in another study (35% versus 66%, P = 0.006). No study reported on
mortality, morbidity or costs.
 Conclusions: A low-GI diet can improve glycaemic control in diabetes without
compromising hypoglycaemic events.
Cochrane Database Syst Rev. 2009 Jan 21;(1)

22. Conclusion
 From all the above all data obtained in various clinical trials
very clearly suggested that ,the mannagment of meal therapy
prooved to be benefecial in weight management in type
diabeties candidates with improved level of glucose .