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Great thread by @Dr__Guess. To me VLCD are like any other dietary intervention, all are v important part of #obesity treatment. But we need to avoid extreme loving or hating, we just need to see things as they are. DiRECT is a great study, but it is not without sig limitations 
https://twitter.com/Dr__Guess/status/1300890553865973762
https://twitter.com/Dr__Guess/status/1300890553865973762
DiRECT showed that VLCD compared to "routine care" was effective in achieving T2 #diabetes remission. This is great, but we need to acknowledge that the 2/3 who did not achieve remission still need to have other treatment options
I also like @TaraKellyRD comment about the prejudice against VLCD. I agree, this exist and should not be the case. But there is prejudice against everything not VLCD, that should be avoided too. As for adherence, lets see the approx data
1000 pt contacted, 400 agreed, 150 received VLCD. Out of those 21% did not engage or withdrew from VLCD. So despite multiple layers of selection still a lot did get on well with VLCD. This is neither small nor negligible amount
When we talk about T2 #diabetes remission with DiRECT, we need to be v clear that the inclusion criteria were very tight, we cannot generalise and the support to pts was great. Ignoring the support and the selection criteria is not wise
I would like to add here that I often use VLCD in the opposite type of pts to that included in DiRECT, and I had great pts success stories .... but I deliver it with plenty of support from DSNs, dietitians and psychology ) and plenty of me too 
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Also we can debate forever whether pre DM is a remission considering the high CVD risk in pre DM, and argue about the lack of data on vascular complications in VLCD and whether VLCD is better than any other diet.
However, what's important to me is that NHS England plan puts #obesity managent in the heart of T2 #diabetes and for that I congratulate them. Also v imp to me is to have multiple treatments options and for pts who respond to VLCD then VLCD should be what they get
But for the rest I need to offer other options, and pts should not feel like a failure if they don't respond to VLCD. Finally, I have many friends in the VLCD world, I love you all dearly, don't take this thread with a negative light
