C/in

Nutr

Proteinmetabolismduringweightreductionwithvery-low-energydiets:evaluationoftheindependenteffectsofproteinandcarbohydrateonproteinsparing13

JorgeAVazquez,UzmaKazi,andNavidMadani

ABSTRACTTheaimofthisstudywastoassesstheinde-

pendenteffectsofcarbohydrateandproteinintakesinproteinsparingduringweightreduction.Forty-eightobesewomenwererandomlyassignedtoconsumeisoenergetic(2500kJ/d)liquiddietsthatprovidedthefollowingamounts(g/d)ofproteinandcarbohydrate,respectively,for28d:50and10,50and76,70and10,and70and86.Theeffectsofcarbohydrateandproteinwereanalyzedbyrepeated-measuresanalysisofvariance(ANOVA).Carbohydratesignificantlyaffecteddailyurinaryammoniaandtotalnitrogenexcretion,stoolnitrogen,andnitrogenbalance.Pro-

tein,independentlyofcarbohydrate,significantlyaffecteddailyurinaryammonia,urea,andtotalnitrogenexcretionbuthadno

effectonnitrogenbalance.Cumulativenitrogenlosses(mmol/28d)werelowerinthehigh-carbohydrategroupsthaninthelow-carbohydrategroups(1869±392and3611±328,

0.003)butweresimilarinthegroupsreceiving50and70gprotein/d(3171

327and2326±430,

respectively,

NS).Theseresultsindicatethatcarbohydrateandproteinhaveindependentbutaddi-

tiveprotein-sparingeffectsduringweightreduction.

AmJ

C/inNutr

1995;62:93-103.

KEYWORDSObesity,weightreduction,nitrogenbal-ance,proteinmetabolism,very-low-energydiets

INTRODUCTION

Very-low-energydiets(VLEDs)arefrequentlyusedinthetreatmentofsevereobesity(1).Thesedietsareprovidedeitherinliquidorsolidformandvaryinenergycontent(1253-3347kJ,or300-800kcal/d)andmacnonutnientcomposition(1,2).Therearemanycontroversiesregardingtheuseofthesediets.Forexample,itisstilluncertainwhetheritispossibletoachievezeroorpositivenitrogenbalanceatallonthesediets,whetherfactorssuchassexorbodycompositioninfluencetheachievementofnitrogenbalance,andwhattheoptimalcom-positionforpreservationofleanbodymassis(1-3).ThemainobjectiveofVLEDsistoproducemaximalweightreductionwhilesparingbodyprotein.However,thereisnoconsensusontheoptimalVLEDcompositiontoachievethisgoal.Inthisregard,themajorareaofdisagreementistherelativeamountsofproteinandcarbohydrateneededforpro-teinsparing.Ontheonehand,thereareVLEDsthatprovidesmallamountsofcarbohydrate

(

30g/d)andcontainmostlyprotein(70-120g/d);ontheotherhand,thereareVLEDsthatprovidegreateramountsofcarbohydrate(75g/d)andlesseramountsofprotein(30-70g/d)

(3-5).

StudiesofproteinsparingduringweightreductionwithVLEDsintheseextremeshaveshownconflictingresults(6-13).Forinstance,somestudieshaveshownproteinsparingwithhigh-protein,low-carbohydrate

(5,

6)VLEDs;othershaveshownbetterproteinsparingwithdietsthatprovidemoderateamountsofproteinbuthighamountsofcarbohydrate(7);andstillothershaveshownnodifferenceatall(8).Nonetheless,therelativeimportanceoftheproteinandcarbohydratecontentsinproteinsparingisdifficulttodeterminefromthesestudies.Forthemostpart,previousstudieshaveinvestigatedasingleamountofprotein(7-9)orasingleamountofcarbohydrate(11).Whenmorethanoneamountofproteinhasbeenexam-ined,theVLEDswerenotisoenergetic(11)anddifferedinotheraspects,includingtheamountofcarbohydrate(6,

8-1

1),andwhenmorethanoneamountofcarbohydratehasbeenexamined,theVLEDswerenotisonitrogenous(6,8,10,11).TheaimofthisstudywastoassesstheindependenteffectsofproteinandcarbohydrateonproteinsparingduringtreatmentwithVLEDs.Westudied48womeninametabolicwandwhiletheyconsumedisoenergeticVLEDsthatprovidedtwoamountsofprotein(50or70g/d)andtwoamountsofcarbohydrate(10on

76g/d).Fiftyand70gprotein/dareconsideredmarginalandsurfeitamountsofprotein,respectively,duringweightreductionwithVLEDs(1-4).

SUBJECTSANDMETHODSSubjects

Forty-eightobesewomenwerestudied.Exceptforobesity,theywereingoodhealthasdeterminedbyhistory,physicalexamination,andlaboratoryevaluation.Thestudywasap-provedbytheInstitutionalReviewBoardoftheUniversityofPittsburghandallpatientsgavewritteninformedconsent.

FromtheClinicalNutritionResearchUnit,DepartmentofMedicine,

UniversityofPittsburghSchoolofMedicine.

SupportedbygrantsDK-39157andRR-00056fromtheNational

InstitutesofHealth.HealthManagementResourcessuppliedHMR70Plusforthestudy.

AddressreprintrequeststoIAVazquez,MontetloreUniversity

Hospital,200LothropStreet,Pittsburgh,PA15213.

ReceivedApril27,1994.AcceptedforpublicationFebruary

27,1995.

a t U ni v of C ol or a d oH l t h S c i C t r D eni s onM em L i b on S e p t em b er 3 0 ,2 0 0 7 www. a j c n. or gD ownl o a d e d f r om

VAZQUEZElAL

Experimentaldesign

PatientswerehousedattheClinicalResearchCenteroftheUniversityofPittsburghMedicalCenterfor31consecutivedays.Toensurethatallpatientsbeganthedietundersimilarmetabolicconditions,patientsconsumedameat-free,weight-maintenancedietfor3d(days-3to-1).Thisdietprovided

75-100g

proteinand10460-12

552

kJ/d(2500-3000kcal/d).

Onthefourthday(day0),patientswereassignedtoconsume

aVLEDthatprovided2500kJ(600kcal)and10gcanbohy-drate/dontoconsumeanisoenengeticandisonitrogenous

VLEDthatprovided75gcarbohydnate/dfor

28d(days

0-28).

Thefirst21patientsconsumedVLEDsthatprovided50gpnotein/dandtheremainderconsumedVLEDsthatprovided70gpnotein/d.Alldietswereprovidedinliquidform.Patientswereencouragedtoconsumenonenergy-containingfluidslib-erally,andactivitywaslimitedtowalkinginthehospitalwand.Patientswereweigheddailyinthemorningaftervoiding.Temperature,pulserate,andsupineandstandingbloodpres-sunesweremeasuredtwicedaily.Electrocardiogramswereperformedweekly.Fastingvenousbloodsampleswereob-tamedatdays0,14,and28oftreatmentformeasurementsofplasma3-hydroxybutyrate(f3-OHB),nonestenifiedfreefattyacids(NEFAs),insulin,thynoxin(T4),tniiodothynonine(13),electrolytes,glucose,uricacid,aminoacids,albumin,prealbu-

mm,

andnetinol-bindingproteinconcentrations.Attheendof

28d,

thedietwaschangedtosolidsthatprovided4184kJ(1000kcal)and100gpnotein/d,andpatientsweredischargedtocontinuedietingathome.

Diets

ThefourVLEDswereisoenergetic(2468-2573kJ/d,on

590-615

kcal/d)andprovidedeither50or70ghigh-qualityprotein/d.Thesourcesofproteinwerelactalbumin,milkpro-tein,casein,andwhey.Foreachamountofprotein,therewasalow(10g/d)andahigh(76or86g/d)carbohydrateVLED.

Forsimplicity,wewillrefertotheseVLEDsasSOP/bC,

50P/76C,70P/1OC,and70P/86C,respectively,wherePisproteinandCiscarbohydrate

(Table1).TheVLEDsalso

providedsimilaramountsofsodium,potassium,calcium,phos-phorus,magnesium,vitamins,andtraceelementsthatmettherecommendeddietaryallowances(14).Alldietswereonigi-nallyinpowderformandwerepreparedfreshdailybyaddingdistilledwater.Compliancewasmonitoredbydirect24-hob-servationofpatientsandbydailymeasurementofurinaryacetoaceticacidconcentration(Labstix;MilesLaboratories,Elkhart,IN).

Urinecollections

Urinewascollectedevery24handstoredwithoutpreser-vativesinplasticcontainerskeptat4#{176}Curingthecollection.

Attheendofeachperiod,thevolumewasmeasuredand

aliquotswereplacedintubescontaining20L2molHC1/Lorafewcrystalsofthymol.Thesampleswerethenfrozenat-20#{176}Cntilanalyzed.Menstrualperiodsoccurredduringthestudiesinafewsubjects.Topreventcontaminationwithblood,theurinecollectionswerediscontinuedfor2-4dduringthoseepisodes.Urineexcretionvaluesduringthemenstruationdayswereextrapolatedfromthenonmenstruationdaysbyusingregressionanalysis.

TABLE1

Dailyenergyandnutrientintakesfromthevery-low-energydiets

(VLEDs)’VLEDgroup50P/1OC50P/76C70P/IOC70P/86CEnergy(Id)2468246825732573

Protein(g)

52.5

50.070.570.0

Fat(g)38.010.0

32.93.0

Carbohydrate(g)10.076.09.386.0Sodium(mg)2230207918911891

Potassium(mg)266027842008

2008

Calcium(mg)198419041044

1400

Phosphorus(mg)9129821147

1000

Magnesium(mg)491508

442

480

Alldietsprovidedvitaminsandtraceelementstomeetorexceedthedailyrecommendeddietaryallowances(14).The5OP/1OCand50P/76C

very-low-energydiets(VLED5)werepreparedbyPfrimmer/Kabi(Erlan-gen,Germany),the70P/1OCVLED

waspreparedbyFoodlek(MorrisPlain,NI),the7OP/86CVLEDwasamodifiedversionofacommercial

product,HMR70Plus(HMR,Boston).Tomakethedietssimilarinenergyandminerals,HMR70Pluswassupplementedwithpolycose(25g/d,Ross

Laboratories,Columbus,OH),NaCI(971mg/d),andKCI(1148mg/d).

SOP,SOgprotein/d;bC,10gcarbohydrate/d;76C,

gcarhohydrate/d;

86C,86gcarbohydrate/d.Stool

collectionandanalysisStoolwascollectedin4-dpoolsandstoredat4#{176}Cntilthey

werehomogenizedwithdistilledwater.Samplesofthehomo-genatewerestonedat-20#{176}Cntilthepoolswereanalyzedfornitrogen.Theresultsoftheanalysisweredividedbyfourtoprovideanestimateofdailystoolnitrogenlosses.Thenitrogencontentofthediets,urine,andstoolweredeterminedbyamicro-Kjeldahltechnique.j3-OHBwasmea-suredenzymatically(15).NEFAsweremeasuredenzymati-callybyusingacommercialkit(WakoChemicalUSA,Rich-mond,VA).Bloodureanitrogen(BUN)andammoniaweremeasuredspectrophotometnically(SigmaChemicalCo,StLouis).Prealbuminandretinol-bindingproteinweremeasuredbyradialimmunodiffusion(BehningerDiagnostic,Somerville,NJ).Insulin,14,and13weremeasuredbyradioimmunoassay(ICNBiomedicalsmc,CostaMesa,CA).PlasmaaminoacidsweremeasuredbyHPLC.Albumin,totalprotein,glucose,anduricacidweremeasuredattheclinicallaboratoriesoftheUniversityofPittsburghMedicalCenter.Nitrogenbalance(mmol/d)wascalculatedasnitrogenintakeminusthesumofthe24-hurinenitrogenplusstoolnitrogenplusinsensiblenitrogenlosses

kg

d.BecauseBUNwasnotmeasureddaily,nitrogenbalancewasnotcorrectedbythechangesinBUNpool.Leanbodymasswasmeasuredbybioelectricalimpedanceanalysis(16).

Statistics

Statisticalanalysesweredonebyusingsegment4Vofthe

BMDPstatisticalpackage

(17).Thedatawereanalyzedby

repeated-measuresanalysisofvariance(ANOVA)usingthecarbohydrate(10and

76g/d)andprotein(50and70g/d)intakesasindependentvariables.Whensignificant

(P<

0.05)interactioneffectswerefoundbyANOVA,pair-wise

testswereusedtoassessdifferencesbetweeneachofthepossiblecomparisonsofinterest.The

valuesfromthese

testswere

a t U ni v of C ol or a d oH l t h S c i C t r D eni s onM em L i b on S e p t em b er 3 0 ,2 0 0 7 www. a j c n. or gD ownl o a d e d f r om

PROTEINMETABOLISMDURINGWEIGHTREDUCFION

adjustedupwardtocontrolforthemultiplecomparisons(18).Therelationofnitrogenbalancetoplasmahormoneconcen-trationswasassessedbyregressionandcorrelationanalysis.Theresultsarepresentedasmean

SEM.

RESULTS

Patientcharacteristicsandgeneraleffectsofdiet

Initially,thegroupsweresimilarinage,weight,bodymassindex(BMI),andleanbodymass(Table2).AllfourVLEDswerewell-toleratedbythepatients.Specifically,diarrhea,pos-turalhypotension,goutyattacks,andarnhythmiaswerenotobservedduringtreatmentwithanyoftheVLEDs.Theonlyfrequentcomplaintwasconstipation.Thisoccurredwithequalfrequencyinallgroupsandwastreatedwithstoolsoftenersandlaxatives.WeightlosswassimilarinallVLEDs.Onaverage,themeanweightlossafter28doftreatmentwas8.4±0.4kg,or7.8±0.2%ofinitialbodyweight(Table2).

Substratesandhormones

Thecarbohydrateandproteinintakeshadindependentef-fectsonvariousplasmasubstrates.ThecarbohydrateintakeaffectedtheplasmaOHB,glucose,anduricacidconcentra-tionsbuthadnoeffectonNEFAs,BUN,andcreatininecon-centrations

(Table3).TheplasmaJ3-OHBconcentrationin-

creasedovertime

(P<

0.001)forallVLEDs.Byday14,

f3-OHB

hadreachedamaximumvalueandstayedatthatconcentrationuntiltheendofthestudy.However,inthe

76CVLEDgroups,theOHBmaximalconcentrationre-mainedwithintherangeobservedinobesepeopleafteranovernightfast,whereasthelOCgroupsexhibitedvaluesintherangeofketosisseenafterashortfastorhigh-proteinVLED

(Table4)(19).

Theplasmaglucoseconcentrationdecreasedovertimeinall

VLEDgroups(Tables3and4).However,thereductionsfrom

days0to14

werelesspronouncedinthe

76C(11-13%)thaninthe1OCVLEDgroups(28-38%).Theplasmauricacidconcentrationincreasedduringtreat-mentwithallVLEDs(Table3).Inallgroups,thehighestconcentrationswereobservedatday14.Theincreaseswerelesspronouncedinthe>76Cthaninthe1OCVLEDgroups.Moreover,byday28thevalueshadreturnedtonearorbelowday-Oconcentrationsinthe>76CVLEDgroups,butremainedelevatedintheIOCVLEDgroups(Table4).TheproteincontentoftheVLEDsdidnotaffecttheplasma

OHB,NEFA,glucose,orcreatinineconcentrations,butsig-

nificantlyaffectedtheuricacidandBUNconcentrations(Table3).IntheSOPVLEDgroups,theBUNconcentrationdecreasedfromdays0to14andremaineddepressedatday28.Incontrast,inthe70PVLEDgroups,theBUNconcentrationincreasedfromdays0to14andremainedelevatedatday28(Table4).Thesechangeswerenotduetoalterationsinkidneyfunctionbecausetheyoccurredindependentlyofchangesinplasmacreatinineconcentrations(Table3).NotethatinallVLEDgroupsthechangesinsubstrateconcentrationsweresmallandtheplasmaconcentrationsofallsubstratesremainedwithinthenormalrangethroughouttheperiodofobservation.

Plasmahormones

Hormonesareknowntoinfluenceproteinmetabolismandtobealteredduringenergyrestriction.Wethereforemeasuredtheplasmaconcentrationsofinsulin,T4,and13atdays0,14,and28oftreatmentwitheachofthefourVLEDs.TheplasmaconcentrationsofinsulinandT3decreasedovertimeduringtreatmentwithallVLEDs(Table3).Thegreaterreductionsoccurredfromdays0to14.Afterthistime,theinsulinandT3concentrationsremainedrelativelyconstant.However,thereductionsforbothhormoneswerelesspro-nouncedinthe

76CthanintheIOCVLEDgroups.

Incomparisonwith13,thechangesthatoccurredin14

concentrationsovertimeweremodest.Exceptforthe70P/86C

VLEDgroup,the14concentrationsincreasedslightly

(1.8-

3.0%)fromdays0to14followedbyreductionsatday28tonearday-0concentrations.13wastheonlyhormonethatwassignificantlyaffectedbytheproteincontentoftheVLEDs(Table3).

Plasmaproteins

TheVLEDcompositionmayaffecttheconcentrationsofcirculatingplasmaproteins.Becauseoftheirshorterhalf-lives,theplasmaconcentrationsofretinol-bindingproteinandpre-albuminareconsideredtobemoresensitiveindexesofproteindeprivationthanareproteinswithalongerhalf-life,suchasalbumin.Fromdays0to14oftreatment,theplasmaconcen-trationsofretinol-bindingproteinandprealbumindecreasedby24-36%andremainedlowatday28

(Table

5).

Atthesame