Category Archives: HEALTHCARE IN THE NHS

Therapeutic effect of weight loss on type 2 diabetes

contrasting very low calorie diets against bariatric surgery

S.N Kreitzman, V. Beeson & S.A Kreitzman

Interest in the use of weight loss to treat type 2 diabetes has intensified in recent years, despite the fact that the rapid therapeutic effect of weight loss on type 2 diabetes has been well known for decades and largely ignored. The renewed interest can be attributed in large part, to a number of publications generated by evidence from bariatric surgery, of the almost universal prompt remission of diabetes with weight loss after successful surgery.
One such study was published in the Journal of Endocrinology and Metabolism in 2004 by Cummings et al “Gastric Bypass for Obesity: Mechanisms of Weight Loss and Diabetes Remission”. In support of their efforts to promote the use of surgical techniques, the authors claimed that no more than 5‐10% of body weight can be lost through dieting, exercise or the few available anti‐ obesity medications. They further write ‐ correctly ‐ that

“Importantly, even mild weight loss confers disproportionate health benefits, in terms of ameliorating obesity‐related co‐morbidities. Nevertheless more substantial and durable weight reduction would improve these ailments more effectively”
…and not correctly that “At present, bariatric surgery is the most effective method to achieve major weight loss. The best operations reduce body weight by 35‐40%.”

Quite a dramatic claim, but surgery is not the only effective means of achieving this amount of weight loss when it is necessary.
There is a readily available alternative to bariatric surgery, without the problematic aspects of bariatric surgery: high morbidity and mortality risk, prohibitively high cost, possible post operative addiction transfer and in consideration of the large numbers of severely overweight people with or without diabetes, extremely limited availability. This alternative is the very low calorie diet. Detailed records have been kept of the weight loss results of every person who has dieted with Lipotrim either at a UK GP practice, hospital clinic or pharmacy for the past 26 years, however, the availability of computer software to replace paper records has made auditing of the results far more practical. Using audit data, accumulated from UK pharmacies, it was easy to identify cases of successful weight losses in excess of 35%. There are many very high weight patients being treated at pharmacy. A recent audit of patients attending a single pharmacy, Prestwich pharmacy in Manchester, had 270 successful patients with initial BMIs in excess of 40. And there are currently over 2000 pharmacies running the service in the UK. Four recent cases will be presented in this report. It has to be emphasised that these people, although at higher BMI than many of the people treated in pharmacy, were participating in the routine Lipotrim weight loss service in pharmacy and the total cost to each was £36 per week.
These four patients did not happen to suffer from diabetes, although many of the people being treated by the pharmacies did present with type 2 diabetes and achieved rapid remission. As has already been recognised, however, this magnitude of weight loss is not necessary for rapid
remission of the diabetes. Most type 2 diabetics show normal blood sugars within the first week of dieting. The selection of these examples is simply evidence to contrast the achievements of VLCD use with the weight losses achieved by surgery. The four women whose initial weight ranged from 14 stone 10 pounds (93.5 kg) to 20 stone 9 pounds (131 kg) collectively lost 25 stone 12 pounds (164.1 kg) . BMI at the start averaged 43 and ranged from 35 to 49.. Following weight loss their average BMI was 27 and ranged from 23 to 31. The percentage of initial weight lost ranged from 35 to 39%. Plots of the weight changes for the 4 cases are presented in Figures 1‐4 This pharmacy weight loss programme is based upon a replacement of all normal foods with a nutrient complete formula. There are many advantages to this approach, especially with severely overweight people. There is now an expanding literature based upon numerous addiction investigations, which demonstrate that in a high percentage of high BMI people, the same metabolic pathways that are generally recognised as part of the addiction profile are shared by people who are using food as a substance of abuse. In the case of every known addiction, it is absolutely necessary to completely stop the abused substance. This is difficult when the substance is alcohol, tobacco or drugs, it is unachievable when the addiction is to food. Food is required in order to stay alive. While ultimately food is required for energy, there is no shortage of energy stored as fat and glycogen in overweight people. What must be supplied in order to keep people healthy are the vitamins, minerals, trace elements essential amino acids and essential fatty acids. Depletion of any of these nutrients will compromise health. Use of a nutrient complete formula provides all the essential nutrients in the absolute minimum number of calories. This allows weight loss at the maximum safe rate, while allowing the person to completely stop eating the foods that they are abusing. This is the only approach that will interfere with the addictive problem and offer a reasonable chance of establishing a normal relationship with food in the future.
There is yet another important benefit to using a food formula instead of traditional foods. With ordinary foods which are derived from various plants and animals and which themselves will differ in nutrient composition and calorie contribution, it is not possible to get an accurate estimate of the energy intake.





Food composition tables present averages from a large number of samples and can differ widely from the composition of a specific sample.
The caloric composition of a defined formula can be known with considerable precision. Therefore dieters can know exactly the number of calories they are eating each day. It is well known that the calorie deficit required to lose a pound of body fat is fixed at 3500. The difference between the calories in the formula and the calories used by the individual based upon genetics and lifestyle will represent the rate at which the 3500 calories is being depleted. Calorie utilization for most people, especially severely overweight people who are not usually involved in massive exercise programmes, does not vary a great deal from day to day. Variations are trivial when it is realised that running a mile only consumes an additional 100 calories, therefore the calories used each day is basically constant. This explains the essentially straight line pattern of weight loss seen in each of the dieter’s weight loss graph. And from the daily changes in weight, it is easy to determine the number of calories used by each individual day after day. This, then will inform the individual of the critical calorie intake that will determine whether weight is gained, lost or maintained. There is no other method to gain this information under real life conditions.
The graphs in figures 5‐8 illustrate the determination of maintenance level intake for the 4 individuals. Cummings et al, in the paper cited above provide estimates of the cost of bariatric surgery (2004 data) represented as QALY (quality adjusted life years) ranging from $5,400 to $36,300 which they state is well under the $50,000 generally regarded in the United States as being cost effective. At £36 per week in 2012, it might be worth considering a VLCD pharmacy programme which will routinely provide weight losses of 1 stone (6.3 kg) a month for women and 1.5 stone (10 kg) for men. And the programme can be used with people who have far less weight to lose than the BMI 35‐40 subjects reported here. These programmes are suitable for obesity prevention in overweight, but not obese people BMI 25‐30. Far more appropriate a contribution to public health and of course prevention of diabetes.

S.N Kreitzman Ph.D, R.Nutr. (UK Registered Nutritionist), V. Beeson & S.A Kreitzman Howard Foundation Research Ltd. Cambridge UK



8-1To fully understand the medical value of nutrient- complete formulated foods as a tool for weight management, there are a few fundamental concepts that need to be explained. These include the protein sparing modified fast; the mechanisms and value of ketogenic diets, minimum safe energy intakes and enteral food formulas. The value of this approach is amply demonstrated by substantial clinical evidence accumulated over a period of nearly 40 years.
Beginning in 1975, a series of reports from the Bistrian and Blackburn medical team demonstrated the value of a very low-energy dietary regime for weight management in a variety of difficult obese patients. This team had the advantage of considerable nutrition expertise and they devised a protein sparing modified fast — essentially a home-concocted Very Low Calorie Dietary formulation that was nutrient complete. Unfortunately the remarkable success (and safety) of this approach was obscured by commercial greed – not by the medical team, but by external commercial exploitation. A commercial product was developed and widely sold that contained virtually no nutrition. it was based upon a hydrolyzed nutritionally incomplete protein (collagen) in cherry syrup. This product was heavily promoted and widely hyped and inevitably, it resulted in a number of deaths.
Quite properly, the Liquid Protein Diets have not been available since the late 1970s. Unfortunately however, a total lack of nutritional understanding led to the assumption that low energy liquid formulations were dangerous as a concept. In fact there are now nearly 40 years of worldwide experience with numerous properly formulated nutritionally complete products which should be evidence enough of safety.
There is an often stated mantra, surprisingly even from nutrition specialists, that there must be some level of calorie intake (in the neighbourhood or 1000 to 1200 calories per day) below which diets become unsafe. Once again, it is simply the superficial understanding of food and nutrition biochemistry that has given this notion some credence. All common foods may be thought of basically as recycled nutrients from the plants and animals we choose to consume. All are complex formulations of the chemicals that make up the composition of those plants and animals. Many of these chemicals are common to all living things and some of them are useful and even necessary for human health. They also contain large numbers of chemicals that are either inert or toxic to other animals, including humans. The key point, however, is that there is no naturally occurring food that contributes all the required nutrients for humans. We therefore require a varied diet to attempt to create a mix that will maximize the chemistry we need and minimise the problematic substances.
The crucial point here is that – given the varying chemistry of the plants and animals we consume — it is virtually impossible to assemble a nutrient-complete daily diet with a total of less than around 1200 calories. When food diets with lower calorie intakes are provided, nutrient deficiencies invariably cause illness. It is very important to note here that it is the nutrient deficiencies — and not the low calorie count — that causes the problems.
When it became clear that nutrient complete enteral feeds could be provided that contained, by design, all the essential nutrients, it demonstrated that the minimum calorie intake was nowhere near the 1200 calorie barrier. In fact, modern formulations have a calorie component determined primarily by the calorie contribution of the essential amino acids and essential fatty acids (and to a lesser extent by the lactose from the necessary milk component, which provides very high quality proteins to the formulations). These limits however are closer to 400 calories per day, not 1200.
The most effective and safe formulations are those that induce ketosis. Ketones are a by-product of the incomplete breakdown of free fatty acids. They are essential for sparing protein utilization and helpful in controlling the hormonal balance between insulin and giucagon, which helps control hunger. Many of the body’s tissues can use free fatty acids as fuel, but critically there are a few (including the brain) that cannot. Unless there are sufficient ketones present, which are water soluble and can pass through the blood brain barrier to provide energy for brain function and survival, the body must de-aminate amino acids from proteins to create glucose. Glucose can not be created from fat. This is why ketones are protein sparing. Virtually all tissues, with the possible exception of liver, can use ketones for energy.
It is clear from the controlled accessibility of very low energy diets through healthcare professionals, that detailed records are available of the successful results of this form of treatment. A large number of these results have been published. Proper nutrition, provided in defined very low calorie formulations, results in maximum safe rates of weight loss and there is considerable evidence to support its value to modern medicine.
S.N Kreitzman Ph.D, R.Nutr. (UK Registered Nutritionist)
V. Beeson Howard Foundation Research Ltd.

PDF version: 8-1-nhsta0002a