To determine the safety of very low calorie diets (VLCD) in regard to their effects on cardiac function. EKG changes were analyzed for 126 women on a VLCD of 3349 kJ/d (800 kcal/d). EKGs were done when the diet was begun, after 3 months of dieting, and at a 6 month follow up after being off the diet for 3 months. Subjects were solicited through advertisements and charged $1,000 for participating after being screened for age, weight, and health status. MAIN OUTCOME MEASURES: EKG QTc intervals, PR interval, QRS interval, ST-T wave changes, and heart rate. RESULTS: Over one-fourth (27.0%) of subjects had normal EKGs at all three time points studied. Sinus bradycardia was the most common abnormality, observed in 60 subjects (47.6%) on at least one of the three EKGs. Fifty-eight (46%) patients had EKGs with ST-T wave abnormalities observed on at least one of the EKGs. Eight subjects (6.4%) had prolonged QTc (more than one standard deviation beyond the average for women) intervals on at least one EKG. None of these eight persons had significant untoward medical consequences. CONCLUSION: A VLCD diet of 3349 kJ/d (800 kcal/d) for up to 3 months is not associated with significant electrocardiographic abnormalities or clinical cardiac complications, provided the patients have low cardiovascular risk at baseline.

Dieting obese subjects are at risk of developing gallstones. A gallbladder motor dysfunction could have a pathogenetic role. The principal aim of this study was to evaluate the long term effects of two very low calorie diets differing in fat content on gallbladder emptying and gallstone formation in obese subjects. DESIGN AND SUBJECTS: Gallbladder emptying in response to meals (breakfast, lunch and dinner) in two different diet regimens (3.0 vs 12.2 g of fat/d) was evaluated by ultrasonography in 32 gallstone-free obese patients on different days, before and during (at 45 d intervals) one or two 6-month weight reduction diets (for the first three months: 2.24 MJ (535.2 kcal), 3.0 g fat/d vs 2.415 MJ (577.0 kcal), 12.2 g fat/d; for the second three months, the same low calorie diet of 4.194 MJ (1002 kcal)/d for both groups). In 10 subjects, bile analysis was also performed. RESULTS: Twenty-two (69%) subjects concluded the study, eleven in each group, and a significant weight loss was achieved by all subjects. Gallstones (asymptomatic) developed in 6/11 (54.5%) (P < 0.01) of subjects following the lower fat diet, but in none with the higher fat regimen. In the dieters during the first three months (very low calorie phase) the higher fat meals always induced a significantly greater gallbladder emptying than the lower fat meals. The cholesterol saturation index initially increased significantly and then decreased, without difference between the two groups. CONCLUSION: In the obese during rapid weight loss from a very low calorie diet, a relatively high fat intake could prevent gallstone formation, probably by maintaining an adequate gallbladder emptying, which could counterbalance lithogenic mechanisms acting during weight loss.

Energy restriction (ER) extends the life span and slows aging and age-related diseases in short-lived mammalian species. Although a wide variety of physiological systems have been studied using this paradigm, little is known regarding the effects of ER on skeletal health and reproductive aging. Studies in rhesus monkeys have reported that ER delays sexual and skeletal maturation in young male monkeys and reduces bone mass in adult males. No studies have examined the chronic effects on bone health and reproductive aging in female rhesus monkeys. The present cross-sectional study examined the effects of chronic (6 y) ER on skeletal and reproductive indices in 40 premenopausal and perimenopausal (7-27 y old) female rhesus macaques (Macaca mulatta). Although ER monkeys weighed less and had lower fat mass, ER did not alter bone mineral density, bone mineral content, osteocalcin, 25-hydroxyvitamin D, 1,25-hydroxyvitamin D or parathyroid hormone concentrations, menstrual cycling or reproductive hormone concentrations. Body weight and lean mass were significantly related to bone mineral density and bone mineral content at all skeletal sites (total body, lumbar spine, mid and distal radius; P: < or = 0.04). The number of total menstrual cycles over 2 y, as well as the percentage of normal-length cycles (24-31 d), was lower in older than in younger monkeys (P: < or = 0.05). Older monkeys also had lower estradiol (P: = 0.02) and higher follicle-stimulating hormone (P: = 0.02) concentrations than did younger monkeys. We conclude that ER does not negatively affect these indices of skeletal or reproductive health and does not alter age-associated changes in the same variables.

ABSTRACT: Severe chronic undernutrition is associated with decreased bone turnover and significant bone loss. However, little is known about the short-term effects of nutritional deprivation on bone turnover. To investigate the effects of short-term fasting on bone metabolism and the contribution of acidosis to these changes, 14 healthy women ages 18-26 (mean, 21 +/- 2 (SD years) were randomized to potassium bicarbonate (KHCO3, 2 meq/kg/day in divided doses) to prevent acidosis or control (potassium chloride, 25 meq/day) during a complete 4-day fast. Bone turnover was assessed using specific markers of formation [osteocalcin (OC) and Type I procollagen carboxyl-terminal propeptide (PICP)] and resorption [pyridinoline (PYRX) and deoxypyridinoline (DPYRX)]. Serum bicarbonate levels fell significantly from 27.0 +/- 3.2 to 17.3 +/- 2.6 mmol/L (P < 0.01) in the control group and were decreased compared to patients receiving KHCO3 [17.3 +/- 2.6 vs. 23.4 +/- 2.4 mmol/L, (P < 0.001)]. Serum total and ionized calcium increased significantly in the control group [9.1 +/- 0.1 to 9.4 +/- 0.2 mg/dL (P < 0.01) and 1.20 +/- 0.03 to 1.23 +/- 0.03 mmol/L (P < 0.05), respectively], but not in patients receiving KHCO3. In addition, serum parathyroid hormone (PTH) levels decreased from 32 +/- 17 to 16 +/- 10 pg/mL (P < 0.05) and urinary calcium excretion increased [86 +/- 51 to 182 +/- 103 mg/day (P = 0.01)] in the control group, but not in patients receiving KHCO3. Serum osteocalcin (OC) and procollagen carboxyl-terminal propeptide (PICP) levels decreased significantly after 4 days of fasting from 9.1 +/- 3.4 to 5.5 +/- 4.2 ng/mL (P < 0.01) and 121 +/- 21 to 46 +/- 13 ng/mL (P = 0.0001) respectively in the patients receiving bicarbonate, and from 10.1 +/- 3.3 to 4.0 +/- 2.9 ng/mL (P < 0.01) and from 133 +/- 22 to 47 +/- 19 ng/mL (P < 0.001) respectively in the control group. The decrease in osteocalcin and PICP during fasting was comparable in both treatment groups. By contrast, urinary excretion of PYRX and DPYRX did not change significantly in either group with 4 days of fasting. These data are the first to demonstrate that markers of bone formation decline significantly with short-term fasting, independent of changes in acid-base status. By contrast, these data demonstrate a direct effect of acidosis in stimulating calcium release from bone during short-term fasting and suggest that acidosis may increase mineral dissolution independent of osteoclast activation and PTH in this experimental model of acute starvation.

AAC comments: This paper give us a sound message that we have to implement alkaline, carbonate water intake during fasting days

Little is known regarding the effects of prolonged calorie restriction (CR) on skeletal health. We investigated long-term (11 years) and short-term (12 months) effects of moderate CR on bone mass and biochemical indices of bone metabolism in male rhesus monkeys across a range of ages. A lower bone mass in long-term CR monkeys was accounted for by adjusting for age and body weight differences. A further analysis indicated that lean mass, but not fat mass, was a strong predictor of bone mass in both CR and control monkeys. No effect of short-term CR on bone mass was observed in older monkeys (mean age, 19 years), although young monkeys (4 years) subjected to short-term CR exhibited slower gains in total body bone density and content than age-matched controls. Neither biochemical markers of bone turnover nor hormonal regulators of bone metabolism were affected by long-term CR. Although osteocalcin concentrations were significantly lower in young restricted males after 1 month on 30% CR in the short-term study, they were no longer different from control values by 6 months on 30% CR.

AIMS: To complete 5-year follow-up of an intensive weight loss programme in established type 2 diabetic subjects. METHODS: Forty-five obese type 2 diabetic subjects, Body mass index (BMI) > 30, expressed interest in an intensive weight loss programme. Group 1 comprised 15 who selected very low calorie diet (VLCD), Group 2, 15 selected intensive conventional diet and exercise (ICD), 15 failed to follow either programme. Group sessions of eight to 15 subjects continued weekly for 6 months, then monthly for 12 months with prospective recording at 3, 6 and 12 months and then annually of quality of life, BMI, waist/hip ratio, blood pressure, fasting blood glucose, serum fructosamine and serum lipids. RESULTS: Weight loss was slower in the intensive conventional diet group than in the VLCD group, but better maintained at 5 years: group 1, 4.8 +/- 6 kg; group 2, 8.9 +/- 4 kg. In the intensive conventional diet group, 5 year high-density lipoprotein cholesterol was increased 1.78 +/- 0.26 mmol L-1 vs. 1.10 +/- 0.32 mmol L-1 at baseline, and diastolic blood pressure reduced 74.5 +/- 13.3 vs. 85.5 +/- 13.3 at baseline, both P < 0.05. CONCLUSIONS: Out-patient VLCD treatment proved safe and effective in overweight diabetic subjects but those who chose conventional diet and exercise had a slower but more sustained weight loss. Diabetic patients willing to attempt VLCD may safely lose sufficient weight to allow major surgery, but weight regain is inevitable. Patients willing to undertake a long-term group programme of conventional diet can sustain significant weight loss for 5 years, but still require antidiabetic medication.

At one time, Paavo Airola, N.D., Ph.D., referred to fasting as the royal road to health and long life. Fasting is a popular method of detoxification for, rather quickly, the body can begin extricating the noxious materials, allowing the body to commence the healing process. Literally, fasting means to deprive oneself of food for a specific period, usually for therapeutic or religious purposes. Medical journals have presented articles that, therapeutically, support fasting as a means of ridding hazardous materials from the body. (Findings reported in American Journal of Industrial Medicine, 1984.)

If there were a down side to fasting, apart from dietary abstinence, it would be the caution required as pollutants are released from internal caches. During a fast, the concentration of toxins in the urine can be ten times higher than normal. After the toxic load is decreased, the body has greater latitude to concentrate upon the healing process.

A professional, who understands the detoxification process, best implements a fast. Many practitioners prefer a juice fast to a water fast, believing the juices expedite the process of detoxification and impose less stress upon the individual. (It is recommended that juices be diluted with distilled water). The nervous system is, particularly, vulnerable to the release of fat-soluble toxins.

Some individuals who fast report being energized, but usually this occurs after repeated short fasts have eliminated many of the toxins and the internal milieu is cleaner.

The initial fasting experience, in a toxic individual, most often produces a feeling of fatigue, as the body does battle with the poisons. For this reason, a working individual may wish to plan a short fast (with the aid of their healthcare professional) over a weekend, when the workload is lighter. The body is extremely engaged as noxious materials are being extracted. Conversely, the digestion of foodstuffs requires a tremendous work effort; therefore, a sabbatical from food, allows the body the energy for detoxification.

Starting a fast and breaking a fast requires special guidance that the cleansing effort is not lost by inappropriate binge eating. Fasting is not for everyone; a hypoglycemic often finds it extremely difficult to fast, even for short periods of time. A guided fast may, however, prove a valid therapy for some individuals, wishing to expedite the detoxification process.

Prolonged total food deprivation in non-obese adults is rare, and few studies have documented body composition changes in this setting. In a group of eight hunger strikers who refused alimentation for 43 days, water and energy compartments were estimated, aiming to assess the impact of progressive starvation. Measurements included body mass index (BMI), triceps skinfold (TSF), arm muscle circumference (AMC), and bioimpedance (BIA) determinations of water, fat, lean body mass (LBM), and total resistance. Indirect calorimetry was also performed in one occasion. The age of the group was 43.3+/-6.2 years (seven males, one female). Only water, intermittent vitamins and electrolytes were ingested, and average weight loss reached 17.9%. On the last two days of the fast (43rd-44th day) rapid intravenous fluid, electrolyte, and vitamin replenishment were provided before proceeding with realimentation. Body fat decreased approximately 60% (BIA and TSF), whereas BMI reduced only 18%. Initial fat was estimated by BIA as 52.2+/-5.4% of body weight, and even on the 43rd day it was still measured as 19.7+/-3.8% of weight. TSF findings were much lower and commensurate with other anthropometric results. Water was comparatively low with high total resistance, and these findings rapidly reversed upon the intravenous rapid hydration. At the end of the starvation period, BMI (21.5+/-2.6 kg/m2) and most anthropometric determinations were still acceptable, suggesting efficient energy and muscle conservation.

All compartments diminished during fasting, but body fat was by far the most affected;
Total water was low and total body resistance comparatively elevated, but these findings rapidly reversed upon rehydration;
Exaggerated fat percentage estimates from BIA tests and simultaneous increase in lean body mass estimates suggested that this method was inappropriate for assessing energy compartments in the studied population;
Patients were not morphologically malnourished after 43 days of fasting; however, the prognostic impact of other impairments was not considered in this analysis.
Fasting even if it is a prolonged fasting is safe in itself. In a group of eight hunger strikers who refused alimentation for 43 days, water and energy compartments were estimated, aiming to assess the impact of progressive starvation. Measurements included body mass index (BMI), triceps skinfold (TSF), arm muscle circumference (AMC), and bioimpedance (BIA) determinations of water, fat, lean body mass (LBM), and total resistance. (Faintuch J. Et al. 19??) The results vere impressive: At the end of the starvation period, BMI (21.5+/-2.6 kg/m2) and most anthropometric determinations were still acceptable, suggesting efficient energy and muscle conservation. Patients were not morphologically malnourished after 43 days of fasting.

Who Should Use a VLCD?
VLCDs are generally safe when used under proper medical supervision in patients with a body mass index (BMI) greater than 30. BMI is a mathematical formula that takes into account both a person's height and weight. To calculate BMI, a person's weight in kilograms is divided by height in meters squared. Use of VLCDs in patients with a BMI of 27 to 30 should be reserved for those who have medical complications resulting from their obesity. VLCDs are not recommended for pregnant women or breastfeeding women. VLCDs are not appropriate for children or adolescents, except in specialized treatment programs.

Very little information exists regarding the usage of VLCDs in older individuals. Because individuals over 50 already experience normal depletion of lean body mass, use of a VLCD may not be warranted. Additionally, persons over 50 may not tolerate the side effects associated with VLCDs because of preexisting medical conditions or need for other medications. Therefore, a physician, on a case by case basis, must evaluate increased risks and potential benefits of drastic weight loss in older individuals. Additionally, people with significant medical problems or who are on medications may be able to use a VLCD, but this too must be determined on an individual basis by a physician.

Health Benefits Associated With a VLCD
A VLCD may allow a severely to moderately obese patient to lose about 3 to 5 pounds per week, for an average total weight loss of 44 pounds over 12 weeks. Such a weight loss can improve obesity-related medical conditions, including diabetes, high blood pressure, and high cholesterol. Combining a VLCD with behavioral therapy and exercise may also increase weight loss and may slow weight regain. However, VLCDs are no more effective than more modest dietary restrictions in the long-term maintenance of reduced weight.

Adverse Effects Associated With a VLCD
Many patients on a VLCD for 4 to 16 weeks report minor side effects such as fatigue, constipation, nausea, and diarrhea, but these conditions usually improve within a few weeks and rarely prevent patients from completing the program. The most common serious side effect seen with VLCDs is gallstone formation. Gallstones, which often develop in obese people, anyway, (especially women), are even more common during rapid weight loss. Some research indicates that rapid weight loss appears to decrease the gallbladder's ability to contract bile. But, it is unclear whether VLCDs directly cause gallstones or whether the amount of weight loss is responsible for the formation of gallstones.

Conclusion
For most obese individuals, obesity is a long-term condition that requires a lifetime of attention even after a formal weight loss treatment ends. Although VLCDs are efficient for short-term weight loss, they are no more effective than other dietary treatments in the long-term maintenance of reduced weight. Therefore, obese patients should be encouraged to commit to a long-term treatment program that includes permanent lifestyle changes of healthier eating, regular physical activity, and an improved outlook about food because without a long-term commitment, their body weights will drift back up the scale.

It has been well documented that a VLCD can produce large and rapid weight loss. A number of studies using appropriate levels of high biologic value protein, vitamin and mineral supplementation, and careful monitoring have shown that the VLCD can be safe. Careful monitoring by a physician experienced in such programs and by a registered dietitian is essential. The maintenance of weight loss must be of key importance throughout the program, necessitating the skills of a multidisciplinary team with medical, nutritional, and behavioral training. It must be recognized that the VLCD is only one part of a total weight management program. The complete program is needed for long-term success. Insurance reimbursement for the services of all members of the health care team, including dietitians, facilitates and supports the multidisciplinary team approach. Potential candidates for this program and health professionals must realize that VLCDs are not for everyone and can be harmful for persons who do not meet the following selection criteria: (a) at least 30% overweight, with a minimum body mass index of 32. (b) free from contraindicated medical conditions: pregnancy or lactation, active cancer, hepatic disease, renal failure, active cardiac dysfunction, or severe psychological disturbances. (c) committed to establishing new eating and life-style behaviors that will assist the maintenance of weight loss. (d) committed to taking the time to complete both the treatment and the maintenance components of a program. Dieters must receive careful medical and nutritional monitoring throughout the program and should continue with nutrition, exercise, and behavioral counseling after cessation of the VLCD until sound eating and life-style habits can be established. The length of time an individual is on the VLCD must be carefully monitored and the VLCD discontinued immediately if medical tests and/or weight loss indicate increased health risks to the client. Finally, potential clients must be adequately warned that there are limitations and risks involved with the VLCD. A VLCD is no magic cure. It requires considerable effort and commitment on the part of both practitioners and participants to ensure the program's success.

Side effects of VLCD
Some patients on a VLCD for 6 to 18 weeks report minor side effects such as fatigue, constipation, nausea, and diarrhea, but these conditions usually improve within a few weeks and rarely prevent patients from completing the program. The most common serious side effect seen with VLCDs is gallstone formation. Gallstones, which often develop in obese people, anyway, (especially women), are even more common during rapid weight loss. Some research indicates that rapid weight loss appears to decrease the gallbladder's ability to contract bile. But, it is unclear whether VLCDs directly cause gallstones or whether the amount of weight loss is responsible for the formation of gallstones.

OBJECTIVE: To determine whether fasting in women would suppress GnRH/LH drive in a high- versus low-gonadal steroid milieu. DESIGN: Case-control study. SETTING: Academic clinical research center. PATIENT(S): Eleven eumenorrheic women and eleven women taking combined oral contraceptives. INTERVENTION(S): Seven of the eleven women in each group underwent an acute 72-hour fast. Blood samples were obtained at 15-minute intervals for 24 hours before the fast and during the last 24 hours of fasting. MAIN OUTCOME MEASURE(S): Twenty-four-hour profiles of LH, cortisol, and melatonin were assessed. Ovarian activity was tracked with estradiol and progesterone levels, and metabolic responses were gauged by measuring thyroid hormone and beta-hydroxy-butyric acid levels. RESULT(S): Fasting increased beta-hydroxy-butyric acid and reduced free thyronine. Fasting in the midfollicular phase had no effect on LH pulsatility or on FSH, estradiol, or subsequent luteal-phase progesterone levels. However, fasting elevated cortisol and resulted in a phase advance in melatonin secretion of 81 minutes in both the midfollicular and luteal phases. CONCLUSION(S): Fasting in women elicited expected metabolic responses and apparently advanced the central circadian clock without compromising reproductive function.

Int J Obes Relat Metab Disord. 1995 Nov;19(11):817-9
Electrocardiographic findings associated with very low calorie dieting.
Seim HC, Mitchell JE, Pomeroy C, de Zwaan M.
Department of Family Practice and Community Health, University of Minnesota, Minneapolis 55414, USA.

OBJECTIVE: To determine the safety of very low calorie diets (VLCD) in regard to their effects on cardiac function. DESIGN: EKG changes were analyzed for 126 women on a VLCD of 3349 kJ/d (800 kcal/d). EKGs were done when the diet was begun, after 3 months of dieting, and at a 6 month follow up after being off the diet for 3 months. SETTING: Subjects were solicited through advertisements and charged $1,000 for participating after being screened for age, weight, and health status. MAIN OUTCOME MEASURES: EKG QTc intervals, PR interval, QRS interval, ST-T wave changes, and heart rate. RESULTS: Over one-fourth (27.0%) of subjects had normal EKGs at all three time points studied. Sinus bradycardia was the most common abnormality, observed in 60 subjects (47.6%) on at least one of the three EKGs. Fifty-eight (46%) patients had EKGs with ST-T wave abnormalities observed on at least one of the EKGs. Eight subjects (6.4%) had prolonged QTc (more than one standard deviation beyond the average for women) intervals on at least one EKG. None of these eight persons had significant untoward medical consequences. CONCLUSION: A VLCD diet of 3349 kJ/d (800 kcal/d) for up to 3 months is not associated with significant electrocardiographic abnormalities or clinical cardiac complications, provided the patients have low cardiovascular risk at baseline.

Scand J Prim Health Care. 1995 Mar;13(1):13-20
Compliance, clinical effects, and factors predicting weight reduction during a very low calorie diet regime.
Hoie LH, Bruusgaard D.
Norsk Legesenter, Oslo, Norway.

OBJECTIVE: To study compliance, clinical effects, and factors predicting weight reduction in obese patients treated with a very low calorie diet (VLCD) regime. SETTING: A general practice in Oslo, Norway. SUBJECTS: 253 obese volunteers, aged 15-72, with a mean body mass index (BMI) of 33.4 (25-51) kg/m2. DESIGN: Open, non-comparative trial. Patients used a VLCD for eight consecutive weeks to achieve weight loss. The following were recorded every second week: weight, blood pressure, anthropometric measurements, compliance, side-effects, and patient acceptability. Blood parameters were tested before and after the trial. RESULTS: VAS-measurements showed that patients found it easy to comply with treatment, and 87.0% completed the study. Mean weight loss was 13.2 (2-33) kg. Blood pressure, serum lipids, and anthropometric measurements were significantly reduced. Side-effects were few and occurred mainly during the first two weeks of the trial. Main factors predicting weight reduction were gender, initial weight, initial BMI, and age. There was no correlation between weight loss and duration of obesity or reported number of weight reduction attempts. By VAS-measurements good acceptability of satiety and taste was recorded, and patients reported improved physical fitness and better quality of life after weight reduction.