In this Exclusive Interview transcript, Scott Isaacs talks with Diabetes in Control Medical Editor Joy Pape during the AACE 2018 convention in Boston about using meal replacements for obesity treatment.
Pape: I’m Joy Pape with Diabetes in Control. And we’re here in Boston at AACE’s 2018 Meeting. And I have the pleasure of speaking with my colleague and friend, Scott Isaacs, specializing in obesity medicine and he’s an endocrinologist, so endocrine problems. So, Dr. Isaacs, you presented yesterday on best practices for using meal replacements in weight management. What do you consider best practices?
Isaacs: Well, when people are using meal replacements they can be losing weight rapidly and so they require close medical supervision. There’s great successes using meal replacements and patients lose a lot of weight but they can get into trouble. And so, we want to do a comprehensive history in physical and we want to do labs, and we want to have periodic medical appointments where we’re specifically monitoring for the types of complications that they can get from rapid weight loss.
Pape: So, I think what you’re saying is it may not be the best idea for people to just go online, find out a place where they can’t be in a medical supervision, and just start doing this on their own.
Isaacs: Well, for safety and also just because we want something to work.
Isaacs: And what I’ve seen is that when someone needs to lose a lot of weight, it’s hard to do it on your own and you really need the support of a physician that’s specializing in obesity medicine and a whole team of professionals; dietitians, exercise physiologists, psychologists, everybody that can work together to help you accomplish that goal because it’s not easy. And so, you need all the support you can get.
Pape: Which takes me to a question I was going to ask you later but I’ll get back to. Needing the support. But a lot of the question too about this rapid weight loss and using meal replacements, is the weight regained, or how do you get back into the real world?
Isaacs: So, those are great questions and that’s the biggest concern, really with any way that you’re losing weight: is weight regained? And when patients lose a lot of weight, they certainly have that risk. And so, the number one thing we can do to prevent weight regain is get into a good behavioral modification program that goes on for a long time. A lot of people when they get their goal weight they start feeling confident, they think they can do it on their own, but the disease of obesity is still there. Even if their body mass index is out of the obesity range, they still have a constant hormonal drive and metabolic drive to regain that weight and that can go on for a really long time. And so, if you can work with somebody that can help you keep that weight off, it makes a big difference. The other thing is that there’s been research looking on how to maintain weight loss after very low calorie diets or low calorie diets using meal replacements. And there are certain strategies that work better than others but the three that seem to work the best are ongoing use of meal replacements, weight loss medications, and high protein diets. Those seems to be the most effective for weight maintenance strategies.
Pape: And you mentioned the different types of calorie diets. Can you tell me the difference between low calorie diets and very low calorie diets using meal replacements?
Isaacs: Okay, yes. So, a low calorie diet is generally above 800 calories but low enough that enables someone to lose weight, what we call getting someone into negative caloric balance. A very low calorie diet by definition is less than 800 calories a day. And so, the weight loss is more rapid and more substantial. There are other definitions of a very low calorie diet. Some people like to calculate the resting metabolic rate and then use 50% of that as the number for a very low calorie diet. And that does have some merits because not everybody is the same. And so, an 800 calorie diet in a small person with low metabolism may be very different than an 800 calorie diet in someone that may weigh 300-400 pounds. And so, it’s probably better to customize this based on the individual person.
Pape: So, how would you explain the medical management of patient losing weight rapidly on low calorie diets with meal replacements?
Isaacs: So, first, we look at the patient and we do the history and physical, and we look at what medications they’re taking, and any potential pitfalls. Many medications do need to be either reduced or just discontinued. Even at the start of a diet, we know that on very low calorie diet, blood pressure drops even before weight drops. And so, we need to reduce the medications or stop medications. Same goes for diabetes medications, we see a really significant fall in blood sugar even before substantial weight is lost. So, medications that make your blood sugar go low like a sulfonylurea, that’s going to be stopped. Insulin, we oftentimes cut it in half. And then as the patients are progressing with the diet, we need to continue making more adjustments and we may need to further reduce diabetes medicines or blood pressure medicines. And it’s a good thing to do. I mean, we love it when we can do that. People like being on less medication and it’s certainly a big benefit of losing weight.
Pape: How often do you see people during their weight loss phase?
Isaacs: So, we have a team and our patients who are losing weight rapidly are going to have contact with somebody on the team twice a week. So, they’re usually coming into a class once a week and then they’ll have a midweek phone call with their health educator, so they’re getting that behavioral connection a couple times a week. They’ll meet with a nurse once a week and just get vital signs and just go over any medical issues they may be having. And then they’ll meet with me or with another physician periodically depending on the risk factor. So, if it’s someone with a lot of risk factors, for example, someone with diabetes on high doses of insulin, I may see them every week. If it’s someone who’s relatively healthy, doesn’t really have — not on any medications, doesn’t have a lot of issues, I may only need to see them once a month. So, we just try to use an individual approach.
Pape: So, you speak about using weight loss medications, anti-obesity medications: any particular ones you use? How do you use them during the period of weight loss and also weight maintenance?
Isaacs: That’s a great question. So, as far as which ones, I use them all. And I really prefer the ones that are approved for chronic use, for long-term use because when we use medicines short-term we oftentimes only get short-term results. But there are two strategies for using medications with patients who are losing weight rapidly. The first is to start a medication on day one to help them comply with the diet and to really enforce everything they’re doing, so they can follow it very closely. But the second strategy I really like, which is not starting a medication at first and waiting, usually around 12 weeks, when the weight loss slows down and then adding in the medication to get additional weight loss. And I tell the patients, “You know, you’re already losing weight pretty rapidly in the beginning and adding a medication at this point may not make that weight loss any faster. But if we wait, you may get more weight loss in the long run doing that.” So, that’s a strategy that I’ve used. There are some data to back that up but we’d like to have more.
Pape: So, I think what you’re saying and I’m familiar with kind of intervening that way at the plateau stage when someone feels like they’re plateauing or things have slowed down. And it’s kind of like success brings more success.
Isaacs: Well, that’s exactly right. I mean, everyone who’s losing weight, eventually the weight loss slows down. That’s just normal human biology. And so, if we can use tools to keep the weight loss momentum going whether that’s through diet or through physical activity or through medications or other approaches that is the way that you can be — have patients be more successful and lose more weight.
Pape: And so, how do you transition patients from the meal replacements back to food without the weight regain? You said that, but how specifically do you do that?
Isaacs: So, transitioning patients is a really important thing because you’re not going to have meal replacements forever. When you’re using meal replacements, it’s for a defined period of time and it’s this goal of rapid weight loss. And then, it’s time to maybe have ongoing but slower weight loss and eventually weight maintenance. But we want you to maintain that weight loss because temporary weight loss is not really a success. If patients have been on just meal replacements, we generally want to gradually add back in regular foods, adding in fruits, vegetables, lean proteins, and whole grains and we usually do that over an eight-week period. The first four weeks are medically supervised and the second four weeks are not necessarily medically supervised.
Pape: You had mentioned earlier though the keeping off the weight, preventing weight regain, meal replacements will still be used. Now, not as they were doing the weight loss phase, but tell me how you use meal replacements.
Isaacs: That’s a great question as well because meal replacements have been shown in many studies to be healthful for weight loss and weight maintenance. And so, they’re tools. So, what is a meal replacement? Well, it’s simply a prepackaged, pre-measured food item that is used for weight loss, so it could be a shake, it could be an entree, a soup, a bar, a cereal. And the idea is that you’re replacing a higher calorie meal with a lower calorie meal replacement. And most of these they’re designed to be filling, so you’re going to fill up with less calories and that’s the idea. And the other thing is that dieting can be very difficult; trying to shop, trying to make decisions about what you’re doing, trying to cook and prepare. And so, meal replacements take a lot of that out of it. Take a lot the guesswork out of it. You know exactly how many calories you’re getting. And also, a lot of the decision anxiety that can come up sometimes trying to think of what’s the next healthy meal you should have.
Pape: And I find that a lot of my patients where they have problems are the celebrations and the holidays. You know, they’re getting out and going places with friends. And they get out and they’re confused, like you said, or they overdo. So, how do you recommend going out to eat with others? How do you recommend this? What should they do with the celebrations using meal replacements? Maybe before they get together with people. How do they do that?
Isaacs: That’s a big challenge. In fact, that’s probably one of the biggest challenges we see with our patients. Those exact situations, so celebrations, birthdays, travel, funerals are a big one as well. And so, if someone is on the rapid weight loss phase and they’re not supposed to really eat outside foods, we do have strategies to prevent that. So, you may want to take extra meal replacements before the event, not just to the point of feeling that you’re not feeling hungry but actually to the point that you’re feeling full. Because when someone is full, it’s really hard to eat something else. If you’re not hungry you might still eat, but if you’re full that makes it more difficult. Other situations or someone doesn’t have to be quite as structured with the meal plan, they may want to enjoy the celebration. And so, it’s okay to give yourself permission to sometimes have the piece of cake or to go to the restaurant and enjoy it with friends, but you want to try to get right back onto your program and really focus on the big picture. So, you don’t have to be 100% but you also don’t want that to be the slippery slope where then it’s something else and something else and it’s hard to really get back on the diet.
Pape: So, what would your top five maintenance strategies be after losing weight?
Isaacs: Top five maintenance strategies after losing weight.
Pape: Yes. I mean, one might — one of them you’ve mentioned might be to still use meal replacements at times.
Isaacs: That is a great one. Sure, we’ll make that one number five, is using meal replacements, using meal replacements strategically throughout your day and throughout your week in situations where you might otherwise have a high calorie food. Number two, I’m going to say exercise. When it comes to weight loss exercise is a small part of it: I tell my patients it’s 10% to 20%. But when it comes to weight maintenance, it’s much more important. And so, getting that consistent exercise on a day-to-day basis will help protect that weight loss and help you maintain it for a longer period of time. Number three is behavior change, that it takes a constant effort. And even after you’ve achieved your goals or even surpassed your goals without the effort of making that behavior change on a day-to-day basis the habits can slip back into the old way and the weight can creep back in. So, that’s a really important thing as well. Family support, very important. If you don’t have a supportive family, it makes it really hard. On the other hand, if the family is supportive, it makes it much easier. So, try to involve friends and family and don’t exclude them from the process. And number one, some people may disagree but I think I’d have to say the number one thing is the medications. And I say that based on the research, that there is really good data to support long-term weight maintenance with some of the newer weight loss medications that are available.
Pape: And is there anything in particular that you want health care professionals to take back that possibly they can use, or maybe refer to when working with patients that need rapid weight loss when using meal replacements? What would you recommend they do?
Isaacs: Well, I would first say that they work. And I think there’s been a lot of confusion or concerns about meal replacements. It’s just mostly out of not knowing about them, but if you look at the data they provide superior weight loss compared to regular foods, consistently. And so, they are tool. And in this day and age which we’re all constantly looking for something that can be effective for our patients and this is something that’s been proven. So, if you want to get started helping your patients with meal replacements, I think a good way to start would be to get some patients on a partial meal replacement plan where they’re having some meal replacements and some regular foods. It doesn’t require quite as much intensive medical supervision. And then, perhaps identifying some practitioners in your area that specialize in this type of weight loss that really have the program set-up with all the education and all the resources needed to help your patients be successful.
Pape: Yes. They really do need the multidisciplinary care approach. And as we know, the patient is in the center of it and very much a part of it.
Pape: So, we hear a lot about intermittent fasting. What can you tell us and what’s your experience been about that?
Isaacs: So, intermittent fasting, it’s an interesting one because the definition is very loose. So, some people would consider intermittent fasting timed feeding, where they’re restricting their meals to a very small portion of the day, six to eight hours out of the day. And the rest of the day, they’re not eating. Another version of intermittent fasting is actually doing very low calorie diets with meal replacements. And some people would say that just being on pure meal replacements is considered fasting. And there was recently a study published, looking at this type of intermittent fasting in patients with diabetes, and what it showed is that patients with diabetes, it’s safe to do intermittent fasting. And in this study they were doing basically three days a week of very low calorie diet using meal replacements. It’s either three days in a row or any three days they chose. So, it certainly was safe, that we didn’t see hypoglycemia. But we also didn’t see as good a weight loss. And so, really I haven’t seen that it’s very effective for weight loss. And perhaps doing a more structured meal plan or working with a physician, doing a low carb diet or some other form of diet may be more effective. Although, I’ll say that there are certain patients that they love it, they do it, especially the timed feeding, I’ve had many that say they like it but I think it’s more anecdotal. And I’d like to see more controlled studies, looking at it in more detail.
Pape: Well, Dr. Isaacs, thanks so much for your work! And is there anything else you’d like to tell us?
Isaacs: I would just say weight loss, it’s a very gratifying field but it’s also a very challenging field, and there’s so much that we still need to learn. And for patients who have tried and not been successful, I would say don’t give up because there’s new things that are on the horizon and trying something different may be just what you need to reach your goals.
Pape: So, we had talked about if someone is on insulin you decrease to maybe half. And getting started, I’m sure you’re looking at their levels and taking other things in consideration. But let’s look at the patient with type 1 diabetes versus a patient with type 2 diabetes,and they’re wanting to start meal replacements, how would you manage that?
Isaacs: So, type 1 diabetes with meal replacements and rapid weight loss is actually not that difficult, because if someone is doing carb counting or if they’re using an insulin pump basically the carbs are just putting in the number of carbs they’re eating and the ratio doesn’t necessarily need to change right away. We do make a small decrease in the long acting insulin or in their basal rate, usually a 10% to 20% decrease in the beginning. And then as they lose more weight that amount may go down and also their carb ration may change. But really it’s still just a standard type 1 diabetes management.
Pape: And type 2?
Isaacs: Type 2 is a different ball game, because many patients with type 2 can discontinue all of their medications at the time that they start the diet. And if not all, most. And so, insulin is usually cut in half or even more substantial reductions, sulfonylureas are discontinued. And other medications, we may stop them as well or we may continue them and stop them later. But there’s a dramatic reduction in the need for medications with type 2 diabetes. There was an article published in the Lancet last year looking at very low calorie diet and diabetes remission. And what was found is at the end of one year, the patients who had lost at least 15% of their body weight, there was an 84% remission in diabetes which was almost identical to the numbers that we see with gastric bypass at the same time. And so, especially with patients who have diabetes relatively recent onset, less than six years, there’s a really high remission rate and this may be one of the best treatments we have for type 2 diabetes.