Meal Replacement Products (MRP)

BY DR. BAYNE FRENCH MD DC

Introduction

Many of you reading this now are lean. But you know or love someone who has struggled with their weight, right? It is critical for all of us to understand that obesity is a chronic disease. A disease categorized by widespread neurologic and hormonal dysregulation. A disease with many drivers and many causes; not a homogenous result of choice, lack of willpower, and gluttony  but rather a heterogenous and extremely complex disease driven by physiological factors largely beyond individual control. It’s chemistry folks, not character. It is also the disease that drives most others. Its burden on human morbidity and mortality is staggering. Much of this suffering and associated diseases are offset by weight loss. The greater the weight loss, the greater the benefit. 

We as a medical institution have done a deplorable job assisting individuals to achieve and maintain a healthy weight. There are many reasons for this (lack of time, lack of knowledge, lack of reimbursement, disinterest, etc.) and I have written about this before. The days of half measures, faulty information, weight bias and terrible advice need to be extincted in a pressing way. In my opinion, every reasonably safe means of intervention including FDA off-label measures, need to be employed. The full-court press of education, advice, coaching and medical intervention designed with sustainable weight loss in mind is becoming an ever greater part of my practice. More and more this is being done remotely, via telehealth and is an emerging and exciting means of healthcare delivery.

In 2016 during my studies for board certification in Obesity Medicine, I was told by an “expert” that it is simply not possible to adequately manage overweight and obesity without the use of meal replacement products (MRP). Most obesity guidelines would not support this notion but hey, this person clearly knew more than I did so I thought “I need to get me some of that”. Until I realized that “that” was largely crappy, chemically enhanced, low fat, amalgamation of items I would not put in my own body. Thus, I never recommended them to one patient. Instead, emphasis was given to help them change their relationship with food. To help them realize the joy of food procurement, preparation and consumption.  Human animals eating human animal food. This approach however was not without its shortcomings.  Many people simply did not enjoy cooking. They had a very limited budget, or were consumed with juggling single parenting, work, school and myriad other factors that frankly made me feel guilty when I complained about my own job. Although not essential for weight loss by any means, a quality MRP many times sure would have come in handy. The traditional teaching was that MRP provides a reliable and convenient means of “energy restriction”, i.e. caloric restriction. I do not operate in the calories in/calories out paradigm anymore. Instead, for me MRP should provide good nutrition, satiety, convenience, portability, and reliability with taste and flavor one looks forward to. 

 

Definition

There is no unifying definition of a meal replacement product. In general a MRP is a discrete food product or drink used to replace usually consumed foods. Some include fiber, vitamins and minerals.  Others simply provide macronutrients (carb, fat, protein), with fiber and vitamins obtained by other means like supplementation. Most MRP’s do not exceed 300 calories per serving. 

One or two meals per day are replaced in a partial meal replacement strategy. This method may be used both for weight loss and weight maintenance. But also for individuals NOT seeking weight loss. The convenience and nutritive value of a quality MRP may be attractive to anyone on the go. 

A full meal replacement strategy is where all daily nutrition is provided via MRP. This method is considered a VLCD (very low calorie diet), and is between 500-800 calories per day. I have assisted individuals perform this but only as a “means to an end”. Primarily to help them shrink their liver and/or lose a large amount of weight prior to bariatric (weight loss) surgery or to become a candidate for a joint replacement. As the Biggest Loser Study shows, these folks more often than not become damaged metabolic goods, with a prompt regain of all their weight loss plus some. Not good. It also requires close medical monitoring.

A hybrid model could include full MRP for a period of time, followed by 2-3 MRP daily with 1 daily meal and a slow increase in meals and reduction in MRP.  As the Obesity Medicine Association says “no matter the context, meal replacements are both convenient and effective”.

 

Rationale for MRP

• Portion control
• Energy/calorie control
• Structured eating
• Stimulus control (avoiding contact with obesogenic foods)
• Stimulus narrowing (drastic simplification of food choices)
• Less cost
• Portability
• Long shelf life

 

What Does the Data Show?

A study described in a 2018 Journal of Obesity article compared two groups.  One used a meal replacement for dinner and the other control group continued their regular diet.  They were followed for 12 weeks and significant differences between the groups emerged. The meal replacement group exhibited significant improvements in waist circumference, body fat mass, and BMI.  These physical changes more importantly resulted in metabolic improvements.  Almost a 10% improvement in blood sugar and 7% improvements in blood pressure were seen in the MRP group.  

A similar study in 2004 followed two groups. One group used two MRP’s per day but both groups were weight loss focused. Weight loss in each group was comparable but “dietary compliance and convenience were viewed more favorably by participants who consumed meal replacements than by those in the conventional weight-loss program”. Hmm, something that can be effective and enjoyed. 

A very large meta-analysis (study method looking at several different studies) was reported on in Obesity Reviews in 2019. Almost 3000 studies were reviewed and 23 were found to meet their criteria, including almost 8000 studied adults. Not only was the use of MRP found to be safe and convenient but actually more effective in the first year than other weight loss interventions that did not include MRP. When MRP was coupled with medical support, patients did even better. And those that received the most support did the best. If you’ve read any of my articles you know that I strongly suggest advocating for YOURSELF primarily through sound education and action. But utilizing the services of properly trained coaches and obesity specialists offers the best outcomes. This study also showed that blood sugar (as measured by hemoglobin A1c) also improved. One conclusion drawn from this meta-analysis is that the employment of MRP is suitable for community use. This means that using one or two MRP per day required NO medical supervision. Yay for that I say, unless you enjoy long waits, white coats and no sense of humor. 

Lancet in 2018 published the DiRECT study. It showed that in patients with Type-2 diabetes Type II Diabetes, 46% of those that lost 15 kg (33 pounds) CURED their diabetes. Meaning they no longer had a disease many authorities considered only manageable, not curable. Maybe I just align with the anti-expert and love to stick it to “authorities” but considering 451 million people in our tiny planet had Type-2 diabetes in 2017and 1.5 million died of it in 2012, a 46% cure rate should at least raise your eyebrows, even if you’re a boring authority. Here’s the rub, weight loss it tough. And the maintenance of weight loss is brutal. It requires an effortful task on the part of patients and medical team to possess the self-care knowledge and skill needed for ongoing efforts. Get knowledge (few providers have it to give), implement knowledge (few patients can with time limitations, financial constraints, and family responsibilities), and repeat forever (yah right). Meanwhile, there are dozens of homeostatic, protective, hormonal mechanisms all conspiring to bring them back to the weight at which they started.  

Ongoing implementation (many term this “compliance” which connotes puppetdom to me) is enhanced by simplicity. And THIS is where MRP can help. In the famous Look AHEAD study, over 5000 patients benefited from MRP as part of intensive lifestyle intervention that resulted in significant weight loss and improvements in blood sugar. MRP was deemed not only effective, but safe and easily delivered.

Nutritional Journal in 2010 published a compelling study comparing a meal replacement plan using Medifast, with a food-based diet plan. The most interesting part of this study was that 7 of the 8 authors were Medifast employees. I’ll move on.

 

Conclusion

I until recently have been reticent in recommending MRP as part of a weight loss regimen. It is apparent to me that it is at least as effective as a full food plan.  Its power is primarily in its simplicity and convenience.  To offer a tool when hunger or cravings kick in as they invariably do.  These adaptive mechanisms can result in decompensation and derailment in the most well-intentioned and motivated patient.  Low carb, higher protein and fat are a must.  This macronutrient ratio results in satiety and lower levels of our hunger hormone Ghrelin.  The vast majority of meal replacement products focus on having a low percentile of fat.  This is because of the calorie-centric focus and needs to go the way of the dinosaurs.  Higher fat equals lower insulin.  When this occurs, all things are possible including higher a metabolic rate, less hunger, less cravings, more energy and a slow but sure shifting of the dial from a fat storage state to a fat burning state. But what if you’re already lean? The healthiest lean patients I see are fat burners. They possess the lowest inflammatory levels (C-reactive protein), lowest insulin levels, lowest triglycerides, highest HDL (favorable cholesterol) and the most favorable LDL particle size and number on advanced cholesterol analysis. They also hurt less, and have less acne and bowel issues. The convenience and packability of an MRP cannot be overlooked. If your interests like mine involve the mountains, backpacks and perhaps a bow and some arrows, you might agree that a packet of quality MRP weighs a bit less than a can of anchovies. 

As with everything involving you, remain at the helm. Collect data, consider opposing views, read and listen to your own body. It’s a short and beautiful voyage.

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