Doctor Referral of Overweight People to Low Energy total diet replacement Treatment (DROPLET): pragmatic randomised controlled trial
BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3760 (Published 26 September 2018) Cite this as: BMJ 2018;362:k3760Linked BMJ opinion
Interventions to treat obesity work—so why am I not celebrating?
All rapid responses
Excess adiposity is described as one of the main risk factors for morbidity and mortality. (1) We are in the midst of a worldwide obesity and type 2 diabetes epidemic. However, there remains much confusion over what constitutes a healthy diet.
It has been established that weight loss may be associated with reversal of type 2 diabetes/insulin resistance. (2)
The need for a nutritious balanced diet and lifestyle are fundamental for good health particularly for the prevention of Type 2 Diabetes and possible complications of this disorder. Do total meal replacements fulfil this remit?
The DROPLET study (Doctor Referral of Overweight People to Low Energy total diet replacement Treatment study) (3) utilises total meal replacement (TMR), one of the key ingredients of which is artificial sweetener (Aspartame).
Excess sugar consumption has led to artificial sweetener replacements being widely introduced. The controversy of consuming diet drinks in place of sugared drinks is still a matter for debate. (4) Although artificial sweeteners have been passed as safe by the FDA and the European Food Safety Authority the research concerning artificial sweeteners is fraught with methodological difficulties, industry bias, and has mixed findings.
Of increased interest is the role of the microbiome and diabetes. Research show artificial sweeteners induce glucose intolerance by altering the gut microbiota (5) It is considered artificial sweeteners can cause a wide range of health problems especially for vulnerable populations such as those with diabetes, epilepsy and pregnancy. We are advised to limit processed food yet these are the very products recommended for weight loss. The total diet replacement (TDR) programme diet recommends eating six times a day, how does this impact insulin secretion in the long term? Can the safety of a meal replacement diet be assessed without thorough research into key ingredients? Sugar as an ingredient is usually labelled with amounts quantified yet artificial sweeteners are less transparent. The recommended daily allowance is therefore unknown and amount consumed incalculable.
Caution is urged before consuming artificial sweeteners without adequate and independent research studies as a priority.
(1) World Health Organization. Global Health Risks: mortality and burden of disease attributable to selected major risks, 2009
(2) Beating type 2 diabetes into remission.BMJ 2017; 358 BMJ 2017;358:j4030
(3) Doctor Referral of Overweight People to Low Energy total diet replacement Treatment (DROPLET): pragmatic randomised controlled trial. BMJ 2018; BMJ 2018;362:k3760
(4) Experts argue over benefits of diet drinks. BMJ 2017; BMJ 2017;356:j58
(5) Suez J, Korem T, Zeevi D, Zilberman-Schapira G, Thaiss CA, Maza O, et al. Artificial sweeteners induce glucose intolerance by altering the gut microbiota. Nature. 2014;51. [PubMed]
Competing interests: No competing interests
Re: Doctor Referral of Overweight People to Low Energy total diet replacement Treatment (DROPLET): pragmatic randomised controlled trial
Dear authors,
Many thanks for bringing the results of such a well-designed trial to the attention of readers of the BMJ. I was very impressed by the number of patients you were able to recruit and retain throughout the follow-up period. I have a few queries about the nature of the trial and your results.
It is now becoming widely accepted that obesity is a problem that disproportionately affects those from a lower socio-economic background, with research from Public Health England showing that more-deprived areas can have as much as five times more fast food outlets than their affluent counterparts (1). You alluded to your population group being “heterogenous for socioeconomic status” and I wondered how this was measured?
It also seems that this intervention requires significant resources i.e. a counsellor to initially see each patient every week as well as the formula used for diet replacement. Was the economic significance of this calculated? With regards to weight loss programmes and novel bariatric techniques, there is often no argument against the interventions being efficacious, however, the reason they are rarely implemented involves complex economic decisions for appropriation of funding by care commissioning groups (CCGs). And how long was each session with the counsellor? Again, with obesity being so prevalent, to implement this intervention at a larger scale would require shorter appointment slots to treat more patients.
Finally, away from the economic aspect of weight loss interventions, were any of these patients followed up for longer than a year? Many interventions of this type show results that plateau at the 1-year mark then weight can often be regained if the intervention or taught behaviours are not continued. Your trial results seem to show that the maximal effect was achieved at 6 months. This fits with the concept of treating obesity as a chronic disease rather than looking for short-term fixes.
In the current climate, I think it is of utmost importance that trials like this continue to be funded and undertaken. Having a greater body of evidence will allow more choice for health policy advisers when deciding which interventions can be applied under the unique challenges/demands of the National Health Service.
Yours faithfully,
Rafid Rahman
1. Fast food outlets: density by local authority in England. Public Health England , June 2018.
Competing interests: No competing interests