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ESPEN Congress Brussels 2005
Low carbohydrate or low fat diet to loose weight:
Pro Low Fat Diets
Arne Astrup
Institut for Human Ernæring
Arne Astrup Head, professor, MD, dr.med.Sci.
Institute of Human Nutrition
Low carbohydrate or low fat diet to loose weight:Pro Low Fat Diets
27th ESPEN Congress – 28 August 2005
Institut for Human Ernæring
Diets and obesityDiets and obesity• Hypocaloric reduced-fat diets for weight loss• Reduced-fat diets for maintenance • Role of non-fat component• Low-carb diets• High protein, normal fat diets• Conclusions
Institut for Human Ernæring
Nugenob Low or high fat diets for induction of weight loss
771 obese subjects of both gender (20 - 50 years) from 8 European centres were enrolled in a randomised, open label 10-weeks dietary intervention study comparing two different hypocaloric (-600 kcal/d) diets with the proportion of total calories from fat of 25 or 40.
Petersen M, Taylor M, Saris W, Verdich C, Toubro S, MacDonald I, Sørensen, TIA, Astrup A. IJO (In press)
Changes in body weightChanges in body weight
Moderate fatModerate fatgroupgroup (n=312)(n=312)
LowLow fatfat groupgroup(n=336)(n=336)
Before Before kg)kg) 100.7 (100.7 (16.0)16.0) 100.2 (16.9)100.2 (16.9)nsns
AfterAfter (kg) (kg) 94.1 (194.1 (15.4)5.4) 93.3 (93.3 (16.1)16.1)nsns
DecreaseDecrease (kg) (kg) 6.6 (6.6 (3.5)3.5) 6.9 (3.4)6.9 (3.4)nsns
Petersen M, Taylor M, Saris W, Verdich C, Toubro S, MacDonald I, Sørensen, TIA, Astrup A. IJO (In press)
The proportion of subjects who lost 10% or more of initial body weight was higher in the low fat than in the moderate fat group (18 % vs. 12 %, P < 0.01).
Petersen M, Taylor M, Saris W, Verdich C, Toubro S, MacDonald I, Sørensen, TIA, Astrup A. IJO (In press)
Results lipids, glucose and insulinResults lipids, glucose and insulinmoderate (n=312) and moderate (n=312) and lowlow--fat fat group group (n=336)(n=336)
Decrease Diff. in change (95% CI)
Low-fat Moderate-fat
Total Chol (mmol/l) 0.36 (0.63) 0.25 (0.55) 0.10 (0.02 - 0.18)
Total TAG (mmol/l) 0.04 (0.41) 0.19 (0.71) -0.09 (-0.16 – (-0.03))
LDL Chol (mmol/l) 0.26 (0.57) 0.14 (0.50) 0.11 (0.03 - 0.18)
HDL Chol (mmol/l) 0.08 (0.18) 0.04 (0.16) 0.04 (0.02 - 0.07)
Insulin (µU/ml) 1.2 (4.9) 1.2 (5.9) 0.3 (-0.5 - 1.0)
Glucose (mmol/l) 0.12 (0.49) 0.14 (0.48) -0.01 (-0.08 - 0.05)
Petersen M, Taylor M, Saris W, Verdich C, Toubro S, MacDonald I, Sørensen, TIA, Astrup A. IJO (In press)
Institut for Human Ernæring
A typical longA typical long--term randomisedterm randomisedad lib Lowad lib Low--fat diet studyfat diet study
0 1 2 3 4 5
3
0
-3
-6
Change in weight (kg)
Intervention
** ** **
**a
Low adherence
High adherence
A reduction in dietary fat from 35%
to 25% of total energy produced a
mean weight loss of 3.3 kg after one year
YearsSwinburn et al. Diabetes Care 2001; 24: 619-24
Institut for Human Ernæring
3 Meta3 Meta--analysis of lowanalysis of low--fat diets fat diets
3 identical outcomes in <12 months trials:• Low-fat diets prevent weight gain in normal
weight subjects and produce a modest but important weight loss in overweight subjects (3-4 kg)
• There exists a linear dose-response relationshipbetween dietary fat-% and weight loss
• Dietary fat 10% of calories• Exercise (ns), smoking cessation, stress coping• One year: -16 kg vs -3 kg weight loss• TG increase, but regression of coronary
atherosclerosis• 5 year: -5.8 kg vs. + 1.5 kg (no difference in
physical activity)• Less than half coronary events
The Lifestyle Heart TrialThe Lifestyle Heart Trial
Ornish et al. Lancet 1990; 336: 129-33Ornish et al. JAMA 1998; 280: 2001-7
Institut for Human Ernæring
Adverse effect of low-fat diets
• The non-fat component– Carbohydrates – sugar – GI - soft drinks– Protein
• Metabolic symdrome - inflammation
Change in body weightChange in body weight
CARMENCARMENCARMENCARMENCARMENCARMENCARMENCARMENCARMENCARMENCARMENCARMENCARMENCARMENCARMENCARMENCARMEN
-3
-2
-1
0
1
2
3² w
eigh
t (kg
)
SCHO CCHO CD CS
group
p<0.05
p<0.001
Saris, Astrup, Prentice et al. Int J Obes
Institut for Human Ernæring
The importance of the nonThe importance of the non--fat componentfat component
Raben et al. Am J Clin Nutr 2002; 76: 721-9
Does sugar in soft drinks make you fat ?Sugar versus sweetener
Weight changes
-2,5
-1,5
-0,5
0,5
1,5
2,5
0 2 4 6 8 10
Weeks
Kg
SucroseSweetener
Group x time, p < 0.001
20 % increase in TG in sucrose group vs. Control(AJCN in press)
Raben et al. Am J Clin Nutr 2002; 76: 721-9
Low-fat vs. Low-fat plus
Gardner et al. Ann.Int.Med. 2005,145:725-9
Institut for Human Ernæring
Berry - Lancet
The diet: < 30 % fat + 250-300 g fruit
+125-150 g vegetables
+25-50 g walnuts/almonds
+ 400-500 g whole grain
Produced a 3 kg weight loss over 2 years
Singh et al. Lancet 360, 1455,2002
Institut for Human Ernæring
Institut for Human Ernæring
Diabetes Prevention Program: Diabetes Prevention Program: National Institute of Diabetes and DigestiveNational Institute of Diabetes and Digestiveand Kidney Diseases (NIDDK)and Kidney Diseases (NIDDK)
Goals for lifestyle treatment:• ≥ 7 % weight loss ( maintained )• ≤ 25 E % from fat• 1200 – 1800 kcal/day• ≥ 150 min brisk walking/ week16 sessions over 6 months, subsequently one session/month.
Age 51 yr; BMI 34 kg/m2; average follow-up 2.8 yr; average weight loss 7% after 1 yrand 5% for study duration
Figure 14: Successful weight loss with a hypo caloric-low fat diet and increased physical activity (n=3234)
Placebo
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0-8
-6
-4
-2
0
2
4
Year of treatment
Weight loss (kg) Metformin
Lifestyle
Figure 15: Reductions in the incidence of diabetes with a hypo caloric-low fat diet and increased physical activity
*Reduction in risk of progressing to type 2 diabetes versus placeboYear of treatment
Cum
ulat
ive
inci
denc
eof
dia
bete
s (%
) RR*58%
40
30
20
10
00 1.0 2.0 3.0 4.0
RR*31%
PlaceboMetforminLifestyle
CRP predicts adverse effect on TG of 6 months high simple-CHO diet
-1.0
-0.8
-0.6
-0.4
-0.2
0.0
0.2
0.4
0.6
Simple CHO Complex CHO Control
a
a, b, c, d
b c d
Brinkman Sørensen et al. (2004)
Institut for Human Ernæring
Diets and obesityDiets and obesity• Hypocaloric reduced-fat diets for weight loss• Reduced-fat diets for maintenance • Role of non-fat component• Low-carb diets• High protein, normal fat diets• Conclusions
Popular high-protein diet books
Low Carbohydrate vs Low Fat(Completers analysis)
0 3 6 9 12-15
-10
-5
0
Low-Fat
Low Carb
Months of Diet
Wei
ght L
oss
(%)
Foster et al NEJM 2003;
Very similar weight loss, but higher drop-out in Ornish and Atkins
RDI: At least 130 g carbohydrate/day
Atkits: 20-50 g/d
Adverse effects: Muscle cramps, headache, weakness, diarheea etc.
Astrup, Larsen, Harper. The Lancet. 2004; 364: 897-9.
Institut for Human Ernæring
Low-carb and physical performance
Institut for Human Ernæring
More adverse effects
• Novel presentation of coeliac disease after following the Atkins' low carbohydrate diet
• van Heel, DA; Dart, J; Nichols, S;Jewell, DP; Playford, RJ
• GUT, 54 (9): 1342-1342 SEP 2005
Institut for Human Ernæring
Conclusions on low-carb• Low-carb diets produce greater initial weight
loss than low-fat diets• Risk factors are improved due to the weight
loss• Long-term weight loss is no better than low-fat• Side effects headache, muscle cramps etc. due
to carb-deficiency and dehydration• Predicted long-term adverse effects: CHD and
cancer
Institut for Human Ernæring
Energy density does matter
Avocado 260 g
(7.7 kJ/g)
Potatoes 450 g(3.6 kJ/g)
Institut for Human Ernæring
Diets and obesityDiets and obesity• Hypocaloric reduced-fat diets for weight loss• Reduced-fat diets for maintenance • Role of non-fat component• Low-carb diets• High protein, normal fat diets• Conclusions
Institut for Human Ernæring
Proposed Hierarchy of SatietyNeed hypothesis-driven studies to determine differences
Protein
Carbohydrate
Fat
fiber
sucrose
mct
fructose
leucine
Institut for Human Ernæring
Can more protein as part of a normalCan more protein as part of a normal--fat diet fat diet improve weight loss ?improve weight loss ?
or
Institut for Human Ernæring
A randomized 6A randomized 6--month trial onmonth trial ontwo fattwo fat--reduced diets: High CHO reduced diets: High CHO versusversus high proteinhigh protein
High adherence can beachieved by providing all foods free of charge
Skov AR et al. Int J Obes 2002; 23: 528-36
DIETARY INTAKE
Baseline(n=50) P
0-6 mo(n=46) P
12 mo(n=41) P
Energy (MJ/d)
MP 9.9 (±0.5) NS 10.8 (±0.4) 0.001 8.2 (±0.4) NS
HP 9.5 (±0.5) 9.0 (±0.4) 8.4 (±0.4)
Protein (E%)
MP 15.1 (±0.6) NS 12.0 (±0.1) <0.0001 13.9 (±0.4) <0.0001
HP 16.1 (±0.5) 24.3 (±0.1) 21.2 (±0.8)
CHO (E%)
MP 44.5 (±1.3) NS 58.6 (±0.2) <0.0001 54.7 (±1.8) 0.005
HP 45.6 (±1.1) 46.3 (±0.2) 48.9 (±1.2)
Fat (E%)
MP 40.3 (±1.2) NS 29.4 (±0.1) NS 31.4 (±1.6) NS
HP 38.2 (±1.1) 29.5 (±0.2) 30.0 (±1.4)
MP: Medium protein group
HP: High protein groupDue A et al. Int J Obes 2004;28:1283-90.
Institut for Human Ernæring
A randomized 12-month trial ontwo fat-reduced diets:
High CHO versus high protein
6
8
10
12
14
16
18
0 1 2 3 4 5 6 7 8 9 10 11 12
Duration (month)
24-h
UN
(g)
Medium-proteinHigh-proteinControl
(n=22)
(n=23)
(n=14)
(n=18)
(n=23)
Urinary Nitrogen excretion
Due, Toubro, Skov & Astrup, Int J Obes (in press)
Institut for Human Ernæring
A randomized 12-month trial ontwo fat-reduced diets:
High CHO versus high proteinWeight loss and fat loss
Skov AR et al. Int J Obes 2002; 23: 528-36
Institut for Human Ernæring
Protein reduces Intra-abdominal fat
-40-35-30-25-20-15-10-50
6 12
Medium-protein
High-protein
(cm
²)
P=0.03
P=0.002
Institut for Human Ernæring
Conclusions
• Intervention studies have shown that replacement of carbohydrate by protein from meat and dairy products (<25% E) in ad libitum consumed fat-reduced diets, improves weight loss.
• The effect has been attributed to the greater satiety and thermogenic effect of protein than carbohydrate.
• No adverse effects have been found on cardiovascular risk factors, kidney function, or bone health – rather beneficial effects !
Institut for Human Ernæring
US recommendations
• AMDR (DRI, Institute of Medicine, USA)Protein:
• Adults: 10-35% • Older children: 10-30%• Smaller children: 10-20 %
Institut for Human Ernæring
Diet, Obesity and Genes
European Commission 6th framework: Food Quality & SafetyCoordinator: Wim Saris (NUTRIM, Maastricht)