Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"

Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Year : 2022 | Month : October | Volume : 16 | Issue : 10 | Page : OE01 - OE06 Full Version

A Review on Obesity and its Management: Focus on Meal Replacement Therapy

Published: October 1, 2022 | DOI:
Pradeep Chowbey, Mahendra Narwaria, Ravindran Kumeran, Nandakishore Dukkipati, Jayashree Todkar

1. Chairman, Minimal Access, Metabolic and Bariatric Surgery and Allied Surgical Specialities, Max Healthcare Institute, New Delhi, India. 2. Chairman, Bariatric and Robotic Surgeon, Asian Bariatrics Pvt. Ltd, Ahmedabad, Gujarat, India. 3. Gastroenterologist, Apollo First Med Hospitals, Chennai, Tamil Nadu, India. 4. Chief Bariatric and Metabolic Surgeon at KIMS Hospital; Managing Director and Chief Bariatric Surgeon, Livlife Hospitals, Hyderabad, Telangana, India. 5. Laparoscopic, Gastrointestinal and Bariatric Surgeon. Director; Dr Todkar Hospital, JT Obesity Solutions, JT Foundations Pune, Maharashtra, India.

Correspondence Address :
Dr. Pradeep Chowbey,
Chairman, Minimal Access, Metabolic and Bariatric Surgery and Allied Surgical Specialities, Max Healthcare Institute, New Delhi, India.


Obesity is one of the major health concerns worldwide. In India, over 135 million subjects are affected by obesity. In the last two decades, the prevalence of obesity has increased rapidly. Several factors such as sedentary lifestyle, increased portion size in diet, environmental factors and genetic predisposition are responsible for the increased prevalence of obesity. Obesity also increases the risk of several disease conditions, which has a negative impact on quality of life, work productivity and healthcare costs, leading to a rise in mortality rates. Asian Indians are at a higher risk of developing obesity related co-morbidities at lower levels of Body Mass Index (BMI) and waist circumference compared with Caucasians. Weight loss is a logical step in the management of obesity. Even a modest weight loss of 5-10% of total body weight has shown to significantly improve health and well-being. A negative energy balance achieved by lesser calorie consumption than expenditure serves as the basic principle for weight loss. The role of Meal Replacement (MR) in the management of obesity is discussed in this review. Studies have shown that MR is effective for safe weight loss. MR is designed to deliver optimum nutrition with a minimum glycaemic index. Optifast by Nestle Health Sciences is one such MR product, which is effective for weight management in individuals with obesity.


Body mass index, Diet therapy, Type II diabetes mellitus, Weight loss

Obesity: The Modern-day Challenge

Obesity is one of the top health concerns across the globe with its worldwide prevalence having nearly tripled since 1975 (1). According to the World Health Organisation (WHO), more than 1.9 billion adults were overweight in 2016, of whom 650 million were obese (1). A systematic review in 2019 reported that more than 135 million subjects in India were affected by obesity (2). Several factors are responsible for the rising prevalence of obesity across the world such as increased portion size in diet, (3) sedentary lifestyle, environmental factors and genetic predisposition (4). Obesity also increases the risk of several disease conditions such as Type 2 Diabetes Mellitus (T2DM), hypertension, stroke, sleep apnoea, etc., and leads to a rise in mortality rates (Table/Fig 1) (5). According to a global report, obesity was found to be a driving factor in deaths among patients with Coronavirus Disease- 2019 (COVID-19), and the fatality rates due to COVID-19 were 10 times higher in countries with high overweight/obesity rates (6).

Definition of Obesity: One Size Does Not Fit All

World Health Organisation (WHO) defines obesity as a metabolic disorder characterised by abnormal or excessive accumulation of fat which presents a health risk (1). Positive energy balance (energy intake greater than energy expenditure), leads to the development of obesity (7). The BMI is used as an indicator of body fatness (1). Currently, the BMI-based cut-offs as recommended by the WHO are 18.5-24.9 kg/m2 for normal, 25.0-29.9 kg/m2 for overweight and ≥30 kg/m2 for obesity (1),(8). These may not be appropriate for all ethnic groups, including Asian Indians as it is based on data from Caucasian populations (8). Asian Indians are at a higher risk of developing obesity-related co-morbidities at lower levels of BMI and waist circumference compared with Caucasians. In being cognisant of this fact, a group of over 100 medical experts from all over India developed a consensus document in which the recommended BMI cut-offs for Indians were different from the global cut-offs proposed by the WHO. According to the consensus statement published in 2009, the BMI cut-off for Asian Indians is, normal: 18.0-22.9 kg/m2, overweight: 23.0-24.9 kg/m2 and obesity: >25 kg/m2 (8).

Benefits of Weight Loss in Subjects with Obesity

Even a slightest weight loss of 5-10% of total body weight has shown to significantly improve health and well-being of an individual. Furthermore, weight loss can aid subjects who are obese with prediabetes to prevent developing T2DM and in the long-term, has a positive impact on cardiovascular mortality. A weight loss of >10% is beneficial in subjects with obstructive sleep apnoea (5). Weight loss leads to a reduction in the risk of certain malignancies and has a positive impact on asthma, gastro-oesophageal reflux disease, hepatic dysfunction, urinary incontinence, infertility, arthritis and depression (5). Further, obesity management plays an important role in the treatment of hyperglycaemia in individuals with T2DM (9).

Management of Obesity

Weight loss is a logical step in the management of obesity. Consuming calories less than the energy expended generates negative energy balance that serves as the basic principle for weight loss. The therapeutic armamentarium for obesity includes a non pharmacological approach constituting physical exercise, diet management and behavioural modifications; pharmacotherapy and surgical procedures (4).


Diet Therapy

Diet therapy is the basic non pharmacological weight loss strategy used widely with or without medical supervision. Various types of diets are followed to lose weight. Although most of the interventions including diet help in initial weight loss, the most challenging task in the long-term is weight maintenance (10). The dieter initially loses weight but fails to maintain the long-term goal and begins to regain the weight. This phenomenon is called weight cycling or the yo-yo effect, where the dieter seeks to lose the regained weight, and the cycle begins again (11). Clinical implementation of a diet for a person with obesity can be challenging. The clinical condition, BMI and personal preferences are important factors when designing the diet. Continuous modifications are required depending on the result of the initial diet (10).

The dietary approaches used to reduce energy intake include a Very Low-Calorie Diet (VLCD), Low-Calorie Diet (LCD), low-carbohydrate high-protein diet, low-fat diet (4) and other dietary patterns such as the ketogenic diet, (12) palaeolithic diet (13) and Diet Approaches to Stop Hypertension (DASH) (14). A LCD is a diet with a reduction of approximately 500 cal/day, whereas, a VLCD diet permits consumption of approximately 800 kcal/day (4). The low-carbohydrate diet restricts carbohydrate intake to 20 gm/day but is rich in protein and fat. In a low-fat diet, the calories from fat are restricted to 0.7 kcal/day (4). A ketogenic diet is constituted of very low carbohydrates, moderate protein and high fat advised for a short-term (12). Palaeolithic diet mostly comprises plant, animal and seafood-based meals (13). The DASH diet recommends a lower-energy-dense eating pattern with a reduction in intake of less healthy fats (total fat intake <25% of the energy), increased proportion of fruits and vegetables and no reduction in the weight of the food one eats (14).

A high protein, high-fibre diet provides satiety and favours weight maintenance. However, nutrient requirements must be met (14). Individuals on diet therapy often regain weight rapidly because of binge-or emotional eating (15). For adherence to diet, a slow but steady reduction in calories is recommended. Other strategies to control food intake include using portion control tools like smaller plates, cups and serving spoons. Smartphone applications could be used for self-monitoring of daily food intake and portion sizes, which favours sustained weight loss (14). Using appropriate proportions of food along with MR has also proven to be beneficial in weight loss. Research studies have shown that a substantial weight loss can be obtained by replacing 1 or 2 meals a day with liquid and solid preportioned food {Partial Meal Replacement (PMR)} (14),(16). For weight management over a long-term, PMR is advised with regular food (atleast one meal), and apart from weight loss, it has also shown to decrease the risk factors of diseases that are weightrelated. In a meta-analysis, no adverse events were reported to the PMR regime, however, there were dropouts noted (16). Achieving significant weight loss can be difficult, time consuming and tedious for subjects with obesity. For weight loss, tailored diet regimens could help (12).

Exercise and Weight Loss

Irrespective of goals for weight loss, exercise training should be part of obesity management as it aids in an acceptable level of weight loss, helps maintain weight and also has cardiovascular advantages. Many subjects regain the lost weight due to non adherence to the regime. The available data shows that subjects with obesity who have lost weight would need a considerable amount of physical activity to prevent regain of weight (17). The risk of all-cause mortality decreases with cardiorespiratory fitness of a high level. Physical activity for atleast 200 minutes in a week is suggested to be followed. However, the form and duration of the activity should be designed as per patient requirements (17). High-Intensity Interval Training (HIIT) comprises of strength training and aerobic exercise. It includes a base fitness level hard intensity training for 20-60 minutes 3-5 times per week, for muscular adaptation, followed by workout alternating with relief periods. HIIT provides benefits in a short span of time. It is preferred to obtain medical fitness prior to starting HIIT (18).

Behavioural Modifications

Changes in physical activity and diet require considerable self-determination that can be achieved through behavioural modifications. The first step is to set realistic, practically achievable goals. Design an appropriate self-monitored weight loss plan (diet+physical activity). Further, identifying and addressing barriers to weight loss including misconceptions is important. Drastic changes in body weight and shape may not be achievable (4). Counselling, continuous motivation and encouragement during follow-up by the medical personnel enhances adherence and allow necessary modifications (4). As per the recommendations by the Obesity Society, maintenance of weight loss at approximately 3-5% of the initial weight produces clinically significant benefits with improvements in control of blood pressure, triglycerides, high-density lipoprotein cholesterol, Glycosylated Haemoglobin (HbA1c) and lowers the risk of developing T2DM (19),(20).


Subjects who fail to achieve weight loss with lifestyle modifications, those with a BMI of ≥30 kg/m2 and without concomitant co-morbidity or subjects with a BMI of ≥27 kg/m2 and having atleast two concomitant co-morbidities may be prescribed conjunctive/additional pharmacotherapeutic agents (4).

Orlistat (lipase inhibitor), lorcaserin (serotonin, dopamine and norepinephrine reuptake inhibitor), phentermine/topiramate extended-release (sympathomimetic amine anorectic/antiepileptic combination), naltrexone/bupropion extended-release (opioid antagonist/antidepressant combination) and liraglutide (glucagon-like peptide 1 receptor agonist) are the drugs approved by the US Food and Drug Administration (FDA) for the long-term treatment of obesity [21-23]. Antiobesity drugs approved in India include lorcaserin and orlistat (24).

Liraglutide, approved by the FDA for chronic weight management among children with obesity aged ≥12 years and adults, is to be used as adjunct therapy with a reduced-calorie diet and physical activity (25). Liraglutide in the dose of 3 mg/day has been approved for the treatment of obesity (26).

The new category of antidiabetic drugs such as Glucagon-Like Peptide 1 receptor (GLP-1R) agonists and Dipeptidyl-Peptidase IV (DPP-IV) inhibitors are being assessed for the outcome of obesity and metabolic traits (27). Novel molecules that act on the melanocortin system of the brain or hunger and satiety peptidergic signalling of the gut-hypothalamus axis have been identified by genetic studies (27). Various potential new targets are currently being evaluated, including vaccines (ghrelin, somatostatin) for weight loss (28).

Once prescribed, the patient should be cautioned and observed for side-effects. A detailed discussion on the pharmacotherapy of obesity is beyond the scope of this review.

Bariatric Surgery

Surgical interventions are recommended for subjects in whom diet and pharmacotherapy failed and have a BMI of ≥40 kg/m2 or those having a BMI of ≥35 kg/m2 along with concomitant co-morbidities (4). Different procedures include vertical Sleeve Gastrectomy (SG), Roux-en-Y Gastric Bypass (RYGB), biliopancreatic diversion with duodenal switch and Adjustable Gastric Banding (AGB) (21),(29). RYGB has shown metabolic benefits that are convincing, while SG produces hormonal changes leading to a better diabetes state (29). AGB done laparoscopically is the least invasive, however, regain of weight is commonly observed (22). Over years, the rate of serious complications following bariatric surgery has reduced, with recent data indicating 5% and 0.3%, perioperative morbidity and mortality rate, respectively (22). Postsurgery weight maintenance is essential to sustain the results. The use of MR could be beneficial in this regard.


The main focus of this review would be on the role of MR therapy in the management of obesity. MRs are calorie and portion-controlled meals, with the benefit of retained food environment of the subject, which favours long-term weight loss and helps maintain weight (30). MR is effective for safe weight loss. These are designed with optimum nutrition, high fibre and a lower Glycaemic Index (GI). MR products are formulations available as a bar or a powder mix (31). Recently, the effectiveness of MR formulations has been studied widely.

Doctor Referral of Overweight People to Low Energy total diet replacement Treatment (DROPLET) study is a multicentre trial conducted in the United Kingdom (UK) for the safety and effectiveness assessment of Total Diet Replacement (TDR). It is a 12-month programme with behavioural support and TDR with MR products (providing 810 kcal/day) for eight weeks following which food was reintroduced. TDR was well-tolerated and led to substantial weight loss and a reduction in the risk of cardiovascular and metabolic disease compared with those on regular support for weight loss (32).

A multidisciplinary, clinical, weight management programme with MR demonstrated a high retention rate (90% at three months and 83% at six months) and excellent outcomes including weight loss of 15±12 kg and a decrease in BMI by 5.1±4.0 kg/m2 in subjects completing two years in the programme (33). MR programmes have also been demonstrated to be effective as adjuncts to bariatric surgery. A review and meta-analysis assessed the effectiveness and safety profile of bridging interventions prior to bariatric surgery in subjects with a BMI of ≥50 kg/m2. A decrease in BMI by 9.8 kg/ m2 (95% Confidence Interval [CI]: 9.82-15.4, p-value=0.0006) was observed with a preoperative liquid LCD programme. Thus, MR can be safely used prior to surgical intervention in individuals who are obese (34).

In a randomised trial among elderly subjects with obesity and osteoarthritis, for three months, either one or two meals were replaced with an artificial nutritional preparation. This strategy resulted in effective weight loss with improvement in lipid profile, blood glucose and blood pressure (35).

A retrospective cohort study in adults with severe obesity analysed the effects of a milk-based MR strategy. The results of 24 weeks study showed a significant reduction in body weight and BMI by week 24 compared with baseline (mean weight loss: 15.9±6.0%, BMI decreased from 50.6±8.0 to 42.6±7.6 kg/m2, both p-value <0.001). A significant reduction in HbA1c (from 66.3±13.0 to 48.3±13.5 mmol/mol, p-value <0.001) and improvement in lipid profiles were observed (36).

Viscous soluble fibre with MR is safe for weight loss. A study included 52 overweight or obese participants (average age 47.1 years, mean BMI 33.8±6.4 kg/m2). For 12 weeks, participants consumed 57 grams of proprietary PolyGlycopleX (PGX?SUP?®#SUP#) MR product at breakfast and lunch each. In addition to MR, they also consumed 5 gm/day of PGX?SUP?®#SUP# fibre in granular, powder or capsule form with 250 mL water. Participants were recommended to consume a total of 1200 kcal/ day (low-fat, low-GI foods to be included for snacks and dinner). By 12 weeks, a significant reduction in weight (-4.69±3.73 kg), waist (-7.11±6.35 cm), and hip circumference (-5.59±3.58 cm) was observed in all participants (p-value <0.0001). The BMI scores (n=51) decreased by 1.6±1.4 kg/m2. The study exhibited short-term weight loss with PGX?SUP?®#SUP#MR and PGX?SUP?®#SUP# fibre used with a controlled dietary calorie intake (37).

A randomised controlled trial included 90 overweight/obese subjects (weight 90.6±11.3 kg, age 47±7.5 years, and BMI 31.5±2.3 kg/m2). One group was the MR Diet group (MRD-G) and another was the fat-restricted LCD Group (LCD-G). Both received similar lifestyle education. For individuals in MRD-G, two daily meals were replaced with a drink that provides low-calorie and high-soy protein. The MRD-G group showed a significant decrease in weight (6.4 vs. 3.1 kg), waist circumference (6.1 vs. 1.8 cm), triglycerides (-19.6 vs.+12.5 mg/dL), leptin (18.2 vs. 6.97 ng/mL) and insulin (4.92. 0.58 μU/mL) levels compared with the LCD-G (all p-value <0.01) (38).

A review of the duration of MR therapy in the randomised trials indicates it to range from a few weeks to a few years. (30),(31),(32),(33),(35),(36),(37),(38) Management of obesity with MR for >1 year has shown to result in a 7-8% reduction in total body weight and only non serious effects have been noted (31). This data indicate that the duration of MR therapy is mainly based on the expected weight loss for the individual, co-morbidities, and ultimately is as per the advice of the treating healthcare personnel.

Optifast (39): A Clinically-proven MR Product for the Management of Obesity and Beyond

A new MR product-Optifast (Nestlé Health Sciences) is used to manage obesity. It provides high-quality protein, fewer calories with a low GI, contains 25 vitamins and minerals, and partially hydrolysed guar gum fibre that enhances satiety (39).

A prospective pilot study was conducted among 20 participants with BMI >30 kg/m2, consulting for weight loss prior to elective surgery (non bariatric). Their meals were replaced with Optifast (800 cal/day). A linear significant decrease in BMI and body fat was observed. Further, a reduction in the level of mean blood pressure, HbA1c and triglycerides were also observed (40).

The Optiwin study revealed that total MR using Optifast+behavioural therapy was highly effective in bringing about significant weight loss compared with the food-based behavioural approach, at weeks 26 and 52 (41). A recent publication states that a weight loss programme comprising MR therapy with Optifast, physical activity, social support and regular medical monitoring is an effective obesity management strategy in community-based gastroenterology practice (42).

In contrast to the widely held belief that the weight that is lost rapidly is also regained quickly, Purcell K et al., demonstrated that weight regain is similar after both gradual and rapid weight loss. In subjects on the rapid weight loss programme, three meals/day (for 12 weeks), and in those on gradual weight loss programmes, one to two meals/day (for 36 weeks) were replaced with Optifast. The amount of weight regained was not related to the rate of weight loss (43). A retrospective observational study was conducted among 10,693 participants (with a BMI of ≥30 kg/m2 or a BMI of ≥28 kg/m2 with ≥2 co-morbid conditions) in behaviour-based, non surgical, non pharmacological, medically supervised weight management programme. This was an 82-week programme comprising three phases: (i) complete MR for 16 weeks, (ii) transition phase from 17 to 29 weeks and (iii) lifestyle maintenance phase from 30 to 82 weeks. Optifast shakes or soups were the predominantly used MR products; in addition, Robard bars were used. From the baseline weight, a maximum of 15.3% weight was lost by month 4. By the end of the 5-year follow-up period, the average change in weight was -5.8% from baseline and almost 50% achieved a clinically significant weight loss of ≥5% (44).

Optifast-based VLCD programmes have also demonstrated beneficial effects in subjects who are obese with T2DM. Lim EL et al., demonstrated that normalisation of both beta-cell function and hepatic insulin sensitivity in subjects with T2DM can be achieved with an Optifast-based VLCD programme, showing that this programme can aid in reversing diabetes (45). This was confirmed in another study by Steven S et al., where an Optifast-based VLCD programme (liquid diet) was accepted and helped achieve continued remission of diabetes for a minimum of six months in 40% of participants who showed response to VLCD (46).

The findings of a multicentre, prospective study among subjects with obesity on a 52-week Optifast programme indicate this to be a highly effective method for weight loss. The authors also stated that for obesity management, the Optifast programme was as effective as invasive interventions such as banding or vertical gastroplasty, as reported in the Swedish Obese Subjects study on individuals with similar initial BMI (47). A randomised controlled trial, comparing VLCD and LCD with Optifast for 21 days preoperatively in subjects undergoing bariatric surgery demonstrated that with both types of diet, there was a significant reduction in liver volume and body weight (48).

In another study, a preoperative weight loss of ≥8% was achieved with an Optifast-based LCD for four weeks. This was associated with a significant increase in the additional weight loss postoperatively for 12 months, shorter operative duration and length of hospital stay (49). Some minimal calorie-free food such as non starchy vegetables is allowed to be consumed during the Optifast programme (45). This ensures adequate satiety and long-term adherence to the programme. For LCD, allowances of quantities of each food in the meals and other nutrients are made. By following the exact protocol, all requirements of macronutrients and micronutrients are met.

The authors of this review met and using their expertise proposed two protocols that would act as guidance for Indian subjects requiring weight loss: (1) Subjects with obesity opting for bariatric surgical intervention, (50) and (2) those not opting for bariatric surgery. Subjects with a BMI of ≥30 kg/m2 are offered a VLCD regime and those with a BMI of ≥27 kg/m2 are offered an LCD regime. An overview of the protocols is given in (Table/Fig 2),(Table/Fig 3). The Optifast MR protocols are advised to be followed under the supervision of healthcare personnel. These protocols have been designed to ensure the individual’s daily nutritional requirements are met (sufficient quantity of protein, essential fatty acids, carbohydrates, vitamins, minerals, and trace elements) and to ensure the weight loss is effective and safe. The recommended number of servings of Optifast MR product ensures that the daily total energy intake is maintained in the range of 800 cal/day during the intensive phase for quick weight loss in the initial 12-week period (exclusive consumption of MR product). This is followed by gradual weight loss during the next 4 to 8 weeks with consumption of upto 1200 cal/day with a mix of Optifast MR product and 1-2 low-calorie meals. Then the individual moves into the maintenance phase where the calorie consumption is restricted to <1500 cal/day and MR product can be eliminated during this phase. The duration of this phase depends on the treating physician based on the patient’s health needs to focus on maintaining weight over the long-term. Optifast MR products are recommended to be used along with cognitive and behavioural counselling (50).


Managing obesity can be challenging, but is achievable through restricted diet, rigorous physical activity, lifestyle modifications, pharmacotherapy and sometimes surgical interventions. MR products support these modifications and give a boost to meet the challenging and tedious journey of weight loss, without compromising on the nutritional requirements. Optifast, a new player, has also demonstrated beneficial effects in subjects who are obese with or without T2DM.

Conflicts of interest: All authors have served on Scientific Advisory boards for Nestle Health Science, India. The meeting for authors to prepare the Optifast MR protocol was arranged by Nestle Health Science. However, no honorarium was paid for participating in the meeting or drafting the manuscript. No other potential conflicts of interest relevant to this article were reported.

Contribution by authors: Conceptualisation and design: PC, MN; Literature search: PC, RK, ND; Short listing and review of articles: PC, JT, MN; Manuscript writing: PC, MN; Manuscript editing and finalisation: PC, MN, RK, ND, JT.


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DOI and Others

DOI: 10.7860/JCDR/2022/58413.16971

Date of Submission: Jun 13, 2022
Date of Peer Review: Jul 18, 2022
Date of Acceptance: Sep 01, 2022
Date of Publishing: Oct 01, 2022

• Financial or Other Competing Interests: None
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• For any images presented appropriate consent has been obtained from the subjects. NA

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