Very-low-calorie diets: downsizing the hospitalised obese patient.
The rising prevalence of obesity and its associated morbidity and mortality are placing significant strain on Australia's health-care system. The present case study examines the weight loss attempts of a 60-year-old male patient weighing 218 kg (body mass index 69 kg/[m.sup.2]) in the setting of an acute hospital ward. The patient was confined to bed, secondary to a previous above knee amputation, and was unable to be transferred or fit safely into a wheelchair because of his weight. He was also unable to return home alone because of his current size. Because of the need for rapid weight reduction, a novel inpatient approach to weight loss was adopted, using a very-low-calorie diet (VLCD) and multidisciplinary team management. The VLCD intervention was prescribed in conjunction with medical management, regular physical therapy, behaviour therapy and dietary counselling. Serial anthropometric and biochemical measurements were obtained throughout the treatment period. The patient achieved an 80-kg weight loss (37% initial body weight) over a six-month hospitalisation. Improvements in obesity-related comorbidities and the patient's functional and independence level were also observed, enabling discharge from hospital to residential care. Total weight loss at 24 months post hospital discharge was 103 kg (47% initial body weight). The use of a VLCD in a motivated individual in a controlled hospital environment, along with input from the multidisciplinary team, resulted in substantial and sustained weight loss with improved health outcomes.
Key words: comorbidity, hospitalised, multidisciplinary, obesity, very-low-calorie diet, weight reduction.
The health risks associated with morbid obesity (body mass index (BMI) > 40 kg/[m.sup.2]) and the difficulties in achieving long-term weight loss in these individuals are well documented. (1-3) The fact that 67% of Australian men and 52% of Australian women are now considered overweight or obese (4) necessitates a broadening of traditional approaches to obesity management. Dietary intervention is still the most common therapeutic tool to combat obesity. However, the success of long-term weight loss through dietary treatment alone, especially in the morbidly obese, is limited and poorly researched. (3)
Currently, bariatric surgery is the only documented approach to achieve significant and lasting weight loss in obese individuals. (1) A recent review reports a mean excess weight loss of 16-43% over three to eight years post bariatric surgery. (4) However, considering the large proportion of obesity in our population, this option is limited in its availability in Australia. Successful non-surgical strategies are required to tackle this growing health problem.
Rapid weight loss for morbidly obese individuals has been demonstrated with the use of very-low-calorie diets (VLCDs). (1,2,5,6) VLCDs generally provide 3350 kJ (800 kcal) or less of energy per day and aim to induce substantial weight loss by means of a 'modified fast' while avoiding the reduction in metabolic rate, severe negative nitrogen balance and electrolyte disturbances associated with starvation. (7) The National Task Force on the Prevention and Treatment of Obesity reported that 90% of patients treated with VLCDs in randomised trials lose 10 kg or more within six months. (7)
With an ever-increasing demand on hospital resources and the need to ensure timely patient care and reduced length of stay, the economic burden of obesity in the healthcare system is significant. Despite this, there are few studies in the literature regarding the use of VLCDs for obese patients in the acute hospital setting. Indeed, instigating VLCDs in this location for the morbidly obese is uncommon. The present case study examines the attempts of a morbidly obese inpatient to improve his functional and health outcomes through weight loss, using a VLCD with input from a multidisciplinary team.
A 60-year-old male patient was admitted to an acute medical ward at Austin Health, a large tertiary care facility in Melbourne in 2003 weighing 218 kg (BMI 69 kg/[m.sup.2]). Presenting complaints included left leg cellulitis and hypoxia. He was confined to bed, secondary to right above knee amputation following a motor vehicle accident 25 years earlier. He was unable to be transferred or fit safely in a wheelchair because of his size. Other relevant medical history includes many of the chronic diseases associated with obesity including cardiovascular disease, type 2 diabetes mellitus, respiratory disease and hypertension. Current medications included simvastatin 40 mg daily, gemfibrozil 600 mg twice daily and oral metformin 850 mg twice daily. He also required 16 hours of ventilatory support per day.
The patient described himself as a 'normal-sized' child, reporting significant weight gain in his late teens and weighing approximately 120 kg by the age of 20 years. He was considered morbidly obese prior to his motor vehicle accident. He reported many weight fluctuations since, and a long unsuccessful dieting history, having previously attempted many of the 'popular' diets reported in the lay press. He had received dietary advice from many dietitians throughout multiple hospital admissions over the years. He described difficulty in adhering to 'low-fat' or 'healthy' eating and had never joined a commercial weight-loss program because of financial constraints. He underwent gastric stapling and apronectomy at the age of 40 years, initially reducing his weight from 180 kg to 150 kg only to regain this weight, and more, in the ensuing years.
Upon referral to the dietitian during this admission, the patient was the heaviest he had ever been and eager to lose weight. Medical staff highlighted the need for significant weight loss in order to improve life expectancy and quality of life. At his current weight the patient was unable to participate in basic self-care or mobilisation. The patient lived alone in government-funded housing, with minimal social or financial supports. Despite healing of the left leg cellulitis and correcting hypoxia, the patient needed to remain on the acute hospital ward until major weight loss occurred, as he was deemed unsafe to return home alone and was unable to be placed in a residential care facility. He was also refused rehabilitation from several facilities because of his size and the subsequent requirement to purchase additional equipment. The conventional recommendation for weight loss of 0.5-1.0 kg per week via calorie deficit of 2.1-4.2 MJ per day (4) was not appropriate for this patient, who required weight loss of at least 30-50 kg in a much shorter time frame.
A multidisciplinary team was involved in the management of this patient. The dietitian was responsible for implementing a nutritionally adequate VLCD, monitoring dietary compliance, anthropometry and nutrition counselling. Medical staff managed the patient's chronic health problems and monitored for possible metabolic, biochemical or physical effects of VLCD treatment. The neuropsychologist was responsible for behavioural therapy and counselling. The occupational therapist assisted with aids and equipment to help with personal care and improve independence. The physiotherapist prescribed an intensive program of hourly bed exercises utilising hand weights and resistance bands to help improve strength, lean body mass and elevate energy expenditure. The social worker was important for effective discharge planning.
The VLCD used was OPTIFAST VLCD (Novartis Consumer Health Australasia, Mulgrave, Vic., Australia), as per the manufacturer's clinical treatment protocol, which includes an additional 2 L of kilojoule-free liquid and two cups of non-starch vegetables daily. (8) OPTIFAST VLCD is nutritionally complete, although contains no fibre, and provides approximately 2000 kJ (450 kcal) of energy per day (Table 1). Following the initial Intensive 12-week period of OPTIFAST VLCD, a three-phase program lasting an additional 16 weeks is recommended where gradual reintroduction of low-kilojoule meals occurs, as per the manufacturer's instructions (Table 2). To assist compliance, a meal plan was provided to the kitchen by the dietitian and food records were completed by nursing staff throughout the period of food reintroduction. The dietitian analysed daily energy intake from these food records using FoodWorks nutrient analysis program (Xyris Software (Aust) Pty Ltd, Brisbane, FoodWorks Professional Edition 1998-2002) with the Nut-tab95 (Aust) food composition database. Communication between the medical team, nursing staff, dietitian, patient and his family ensured there was no access to any other food outside of that provided from the hospital's food service.
Baseline anthropometry including height, weight and waist circumference was obtained prior to implementation of the VLCD. Initial weight was measured on bed scales; however, a repeat weight was unable to be obtained because of breakage of equipment under the patient's weight. The patient was thus unable to be re-weighed until it was deemed he was below 180 kg, when he could then be weighed on wheelchair scales. Waist circumference measurements were recorded monthly; however, these could not be obtained as accurately as anthropometry guidelines recommend,9 because of the patient's above knee amputation (therefore unable to stand) and morbid obesity (unable to palpate anatomical markers). A modified version of measuring occurred whereby the patient was sitting upright without upper-body clothing, and the same dietitian obtained each circumference measure at the level of the umbilicus. Biochemical data including urea, creatinine, electrolytes, liver function tests, C-reactive protein, fasting lipids and Hb[A.sub.1c] were measured throughout the VLCD treatment program. Alterations to medication dosages were made as required. The patient was also commenced on topiramate at a dosage of 200 mg per day (off-label) during the admission period. Topiramate is an anticonvulsant medication with a known side-effect of weight loss. (10)
[FIGURE 1 OMITTED]
Throughout admission, the patient was assessed by several residential care facilities in an attempt to facilitate discharge from hospital, which was the ultimate outcome measure for this patient. The patient consented to the collection of data and publication of the present case study, which was also approved by the Austin Health Human Research Ethics Committee.
The patient's BMI on admission was 69 kg/[m.sub.2] (height 1.78m, weight 218 kg). At six months, weight had decreased by 37% to 138 kg (BMI 44 kg/[m.sub.2]; Figure 1). Waist circumference decreased markedly over the same period from 190 cm to 161 cm, a loss of 15% from his initial measurement (Figure 1).
Variations to the dietary treatment protocol were made as required, in consultation with the patient, during regular dietetic reviews (at least twice weekly) and with guidance from the medical team. Changes included increased quantity of vegetables and inclusion of fruit to treat constipation and hunger, provision of higher-carbohydrate vegetables due to hospital menu limitations and provision of soft vegetables due to poor dentition. These changes resulted in a greater total kilojoule intake throughout the VLCD treatment period (Figure 2); however, total energy intake was still consistent with the definition of a VLCD and significant weight loss continued to occur. Nutrition education regarding healthy eating, energy density and portion control also occurred during regular counselling sessions. This education aimed to prepare the patient for the later VLCD stages where regular meals are reintroduced and to ultimately instil lifelong healthy eating habits to maintain weight loss. The patient's cardiac failure and subsequent fluid restriction (1500 mL/day) was not consistent with the total fluid intake recommended. A compromise of 2000 mL/day was reached, with close monitoring of the patient's cardiac function.
[FIGURE 2 OMITTED]
Renal and liver function remained stable throughout the VLCD treatment period. Albumin was low for the first two weeks of the VLCD (29 g/L) consistent with cellulitis, but returned to normal (37 g/L) when infection cleared. Metformin was ceased at the beginning of the VLCD and Hb[A.sub.1c] decreased from 7.4% at baseline to below 6.0% within three months allowing metformin to be ceased permanently. Blood lipids were within the normal range at commencement of the VLCD because of hypolipidaemic agents, which were ceased during the Maintenance phase of the program. Requirement for ventilation was reduced to four to six hours per day.
The multidisciplinary team met weekly throughout the patient's admission to re-evaluate management and discharge plans. After six months, there was a marked improvement in the patient's function and he was able to participate in the majority of his personal care and transfer from his wheelchair independently A suitable residential care facility was then identified and the patient discharged.
At discharge the patient was in the Transition phase of the OPTIFAST VLCD program, consuming one hypocaloric meal daily plus two VLCD drinks. For the ensuing six-week intervention period, the dietitian reviewed the patient via telephone to ensure dietary compliance and appropriate reintroduction of food. Following this, three- to six-monthly reviews of dietary intake, weight and abdominal circumference continued. Two and a half years since commencement of the VLCD treatment the patient's weight was 115 kg, a total weight reduction of 103 kg (47% initial body weight), with gradual weight loss ongoing towards his goal weight of 100 kg.
Documented use of VLCDs in the acute hospital setting is limited. Only one study has investigated the efficacy of VLCDs versus conventional dietary treatment in obese patients in a hospital setting. (6) Patients randomised to a VLCD, while losing a similar amount of initial weight over 12 days as those following a hypocaloric diet (5-8 kg), lost significantly more weight and were able to demonstrate maintenance of their initial weight loss at one-year follow up. In comparison, our case study subject lost a total of 80 kg (37% initial weight) over a six-month hospitalisation.
Several studies have shown that rapid initial weight reduction in obese subjects produces better long-term retention of that weight loss (2,3,11) and VLCDs are thought to be superior to other dietary therapies in initiating this. A recent review of the literature reported that studies using VLCDs tend to observe greater weight loss at 12 months follow up when compared with standard hypocaloric diets; (12) however, the difference was not statistically significant. VLCDs have also been shown to promote greater weight loss and a more sustained benefit when used in morbidly obese individuals (BMI > 40 kg/[m.sup.2]) compared with overweight or 'mildly' obese subjects. (13) The weight loss seen in the present case study supports these aforementioned studies.
In addition to weight changes, measurement of other parameters such as waist circumference, glycaemic control and reliance on ventilatory support also gave vital feedback to both the patient and multidisciplinary staff regarding his progress. Despite the limitations in obtaining accurate waist circumference measures in this patient, as is encountered with all morbidly obese individuals, the ongoing reduction in waist circumference was significant enough to monitor improvement. The limitations of using food records are well documented, (9) but were not considered to significantly impact on verifying a VLCD in this instance, as total energy intake remained well within recommended limits. Glycaemic control typically improves within one week of commencing a VLCD, (7) thus close monitoring of blood sugar levels in patients with diabetes is required. A study of 40 obese ambulatory patients with type 2 diabetes mellitus receiving a VLCD demonstrated significant weight loss of 15% initial body weight and reduction in the need for insulin, oral hypoglycaemic agents and antihypertensive medication. (14) Our results are consistent with the findings of that study. In addition, improvements in sleep apnoea, respiration and cardiac failure also occurred in the case study patient, which are well documented elsewhere. (15) One shortfall of the current study is that quality-of-life measures regarding patient tolerance to the VLCD were not obtained during the treatment period. However, functional quality-of-life measures could be gleaned, with the patient reporting substantial improvements in self-care and independence.
Debate regarding the ethics of advocating highly prescriptive and restrictive means for weight loss (such as a VLCD) among dietitians is evident, with controversy relating to their safety and long-term efficacy. Serious complications, including death, from the use of VLCDs without medical supervision were reported in the 1970s. (7) These early VLCD formulations contained protein of low biological value and have since been reformulated to ensure they are 'complete', containing high-quality protein, additional carbohydrate, essential fatty acids, vitamins and minerals.
The literature agrees that use of VLCDs as a monotherapy has limited success in maintaining weight loss in the long term. (2,3) At five years follow up, individuals who initiated weight loss with a VLCD have similar long-term outcomes to those following conventional low-calorie diets. However, to prevent weight regain the literature suggests that the initial VLCD phase should be followed by a combination of hypocaloric diet, behaviour modification, increased physical activity and active follow up. (1-3,7,11) Input from the multidisciplinary team for the case study patient was essential in ensuring all aspects of the weight management program were adhered to and likely contributed to the longer-term success seen.
The contribution that topiramate may have made to the weight loss seen in the present case is difficult to ascertain exactly, but is likely to be minor. A six-month randomised controlled trial of topiramate's effect on weight loss in healthy subjects demonstrated a mean weight loss of 6.3% initial body weight in those receiving an equivalent dose of topiramate to the case study patient (equal to 13.7 kg in this patient). (10) Considerations for its use include adverse side-effects relating to central nervous system disturbances, (10) and the 'off-label' nature of its prescription.
'Extreme' calorie restriction in the acute hospital setting may be of benefit in cases where comorbid medical conditions are high and significant weight loss is required. Although this article describes the management of only one case, it demonstrates successful weight loss using a VLCD in an individual suffering such comorbidities. Of key importance to achieving weight reduction and improving functional and health outcomes was input from the multidisciplinary team, patient motivation and active follow up after the intervention period. Thus a novel approach to weight loss, such as the use of a VLCD as described in this environment with input from the multidisciplinary team, could be considered by hospital-based practitioners. However, it is acknowledged that further evidence from long-term randomised controlled trials in the ambulatory and hospital populations is required to evaluate the effectiveness of VLCDs and other dietary therapies in the treatment of morbid obesity.
The authors wish to acknowledge Ms Leonie Pearce for her support of the project, Dr Tim Crowe for critically reviewing the manuscript, the multidisciplinary team at Austin Health who contributed to patient management and the patient for agreeing to participate.
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4 National Health and Medical Research Council. Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults. Canberra: Commonwealth of Australia, 2003.
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8 Novartis Consumer Health. OPTIFAST[R] VLCD Clinical Treatment Protocol. Mulgrave: Novartis Consumer Health Australasia, 2003.
9 Gibson RS. Principles of Nutrition Assessment. New York: Oxford University Press, 1990.
10 Bray GA, Hollander P, Klein S et al. A 6-month randomised, placebo-controlled, dose-ranging trial of topiramate for weight loss in obesity. Obes Res 2003; 11: 722-33.
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15 Anderson JW, Konz EC. Obesity and disease management: effects of weight loss on comorbid conditions. Obes Res 2001; 9 (Suppl. 4): 326S-34S.
Brooke CHAPMAN and Helen LONGTON
Department of Nutrition and Dietetics, Austin Health, Melbourne, Victoria, Australia
B. Chapman, MNutrDiet, APD, Dietitian
H. Longton, MNutrDiet, APD, Senior Dietitian
Correspondence: B. Chapman, PO Box 5555, Heidelberg, Vic. 3084, Australia. Email: firstname.lastname@example.org
Table 1 Nutritional analysis of OPTIFAST very-low-calorie diet (8) Per three sachets (120 g) daily Per sachet (40 g) intake Energy--kJ (kcal) 638 (152) 1914 (456) Protein (g) 17.3 51.9 Carbohydrate (g) Total 15.0 45.0 Sugars 11.8 35.4 Fat (g) 2.3 6.9 Table 2 OPTIFAST very-low-calorie diet phases of treatment (8) Recommended daily energy intake, kJ Phase of treatment Time frame (kcal) Intensive Weeks 1-12 1890 (450) Transition Weeks 13-18 3360 (800) Maintenance Weeks 19-22 4200 (1000) Stabilisation Weeks 23-28 5040 (1200)
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|Title Annotation:||CASE STUDY|
|Publication:||Nutrition & Dietetics: The Journal of the Dietitians Association of Australia|
|Date:||Jun 1, 2007|
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