174

AmJClinNutr

Similarweightlosswithlow-orhigh-carbohydrate

2

AlainGolay,Anne-Fran#{231}oiseAllaz,YvesMorel,NicolasdeGeraldReaven

ABSTRACTThe

goalofthisstudywastoevaluatetheeffectofdietsthatwereequallylowinenergybutwidelydifferentinrelativeamountsoffatandcarbohydrateonbodyweightduringa

6-wkperiodofhospitalization.Consequently,43adult,obese

personswererandomlyassignedtoreceivedietscontaining4.2MJ/d(1000kcal/d)composedofeither32%protein,15%carbo-

hydrate,and53%fat,or29%protein,45%carbohydrate,and26%

fat.Therewasnosignificantdifferenceintheamountofweightlossinresponsetodietscontainingeither15%(8.9

0.6kg)or

45%(7.5

±0.5kg)carbohydrate.Furthermore,significantde-creasesintotalbodyfatandwaist-to-hipcircumferencewereseen

inbothgroups,andthemagnitudeofthechangesdidnot

vary

asafunctionofdietcomposition.Fastingplasmaglucose,insulin,cholesterol,andtriacylglycerolconcentrationsdecreasedsignifi-cantlyinpatientseatinglow-energydietsthatcontained15%carbohydrate,butneitherplasmainsulinnortriacylglycerolcon-

centrationsfellsignificantlyinresponsetothehigher-carbohydratediet.Theresultsofthisstudyshowedthatitwasenergyintake,not

nutrientcomposition,thatdeterminedweightlossinresponsetolow-energydietsoverashorttimeperiod.

AmJClinNutr

1996;63:174-8.KEYWORDSObesity,weightloss,low-carbohydratediet,high-carbohydratediet

INTRODUCTION

Althoughthereislittleargumentthatobesityconstitutesa

healthhazard(1-4),therearewidelydifferentopinionswhen

attentionisfocusedonhowtobringaboutweightlossinobeseindividuals.Whenevaluatingtheefficacyofweight-losspro-gramsitisnecessarytodifferentiatebetweenconsiderationsof

therelationbetweenchangesinenergybalanceandweightloss

(5,

6),theabilityofindividualstocomplywithaweight-lossdiet(7),andthelong-termsuccessofanyweight-lossprogram

inpreventingareturntotheoriginalweight(8-10).Thefirstof

theseissuesappearstobethemoststraightforward,buteveninthis

instance,consensushasnotbeenreached.Forexample,ithasbeenarguedthatlow-fatdietsleadtobetterweightloss

(

11),butdatafromAlfordetal(12)indicatethatbothweight

lossandchangesinassociatedmetabolicvariablesweresimilar

whenpatientswereprescribed5.0-MJ/d(1200-kcal/d)diets

containinglow,moderate,andhighproportionsofcarbohy-drate.Thepresentstudywasinitiatedtoextendtheseobserva-tions,andinvolvedacomparisonin43obesepatientsofthechangesinweightandseveralfacetsofcarbohydrateand

Tonnac,SvetalinaTankova,and

lipoproteinmetabolismthatfollowedtheinitiationoflow-energydietsconsistingofeither15%or45%ofenergyfrom

carbohydrate.Toincreasedietarycompliance,patientswerehospitalizedfortheentiredurationofthestudy,duringwhich

timetheyalsoreceivedbehavioralandnutritionaleducation.

SUBJECTS

ANDMETHODS

Forty-threeadult,obesepatientswerestudiedbeforeandaftera6-wkperiodofhospitalization.ThesesubjectshadbeenreferredtotheObesityOutpatientClinicoftheDepartmentofMedicineatGenevaUniversityHospitalfordietarytreatmentoftheirobesity.

Duringthefirstvisit,itwasdecidedonthebasisofahistory

offailuretoloseweightinresponsetoambulatorytreatmentthattheseindividualswouldbenefitiftheywerehospitalizedforthefirst6wkoftreatment.Criteriaforadmissionincluded

abodymassindex(kg/rn2)

30,strongpersonalmotivation,

andtheabilitytoparticipateintherequisiteamountofphysicalactivity.Patientswithobesitysecondarytoendocrinedisease,

aswellasthosewithpsychiatricdiagnoses,wereexcluded

fromthestudy.Theprotocolwassubmittedtoandacceptedby

theethicalcommitteeoftheDepartmentofMedicineatGenevaUniversityHospital.

Inadditiontoalow-energydiet,subjectsparticipatedina

structured,multidisciplinaryprogramthatincludedphysicalactivity,nutritionaleducation,andstandardbehavioraltech-niques.Exerciseconsistedof1hofaerobicexercisetraining

perdayand1hofunderwaterphysicalactivityperday.

Nutritionaleducationwasprovidedbyaregistereddietitian

twiceaweek(onceinagroupsessionandonceindividually).Thebehavioralapproachconsistedofsixsessions,duringwhichissuesofself-control,cognitiverestructuringreinforce-ment,andrelapsepreventionwereaddressed.

Onadmissiontothehospital,patientswererandomlyas-signedtoreceivedietscontaining4.2Mi/d(1000kcal/d)thatconsistedofeither15%or45%ofenergyascarbohydrate.

FromtheDepartmentofMedicine,GenevaUniversityHospital,and

StanfordUniversitySchoolofMedicineandGeriatricResearch,Education

andClinicalCenter,DepartmentofVeteransAffairsMedicalCenter,Palo

Alto,CA.

AddressreprintrequeststoAGolay,DiabetesTreatmentandTeachingUnit,DepartmentofMedicine,UniversityofGenevaHospital,1211,Geneva14,Switzerland.

ReceivedNovember

14,1994.AcceptedforpublicationOctober17,1995.

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

WEIGHTLOSSWITHLOW-ORHIGH-CARBOHYDRATEDIETSI75

‘

E

±SD.BP,bloodpressure.

Baselinecharacteristicsofthetwoexperimentalgroupsarelistedin

Table1.The

groupswerecomparableintermsofsexdistribution,age,bodymassindex,andbloodpressure.

Afterbaselinemetabolicdatawereacquired,thepatients

werestartedononeofthetwoexperimentaldiets.Composi-tionsofthetwodietsareshownin

Table2.Both

dietscon-

sistedofnaturalfoods.

Recipesandmenusofvariousfooditemswerestandardized.A7-drotationalmenuwasused.Themenusprovidedsimilarnutrientcompositionbutoffereddi-versefoods.ItemizedcompositionsofmealsfromIdoftherotationmenuforthelow-carbohydrateandhigh-carbohydratedietsaregivenin

Table3.

Dailyenergyintakewasdistributedamongbreakfast

(22%),

lunch(33%),dinner(33%),andbedtimesnack(12%).Thetotalenergyandproteincontentsofthetwodietsweresimilar.Energyintakewascarefullymeasuredforeachpatient.Allsubjectswereinstructedtoeatallfoodsandadietitianwaspresentduringeachmealtoimprovecompliance.Toverifycompliancewiththediet,patientscompletedal-dfoodrecordonceaweekduringthe6wkofthestudy.Thesefoodrecords

tookthequalityandthequantityoffoodconsumedintoac-

count.ThesoftwarePRODI3+wasusedtocalculatealimen-taryplansandfoodrecords(13).FoodcompositiontablesusedwerefromSoucietal(14)andRenaudandAttil(15).

Theabsoluteamountofcarbohydratewasthreetimeshigher

inthe45%-carbohydratedietthaninthe15%-carbohydratediet

(115±14comparedwith37±Sg),andtheamountoffatwas

lessinthe

45%-carbohydratediet(30

±5

comparedwith60

5g).Bothdietscontainedsimilaramountsofsaturatedfat

(

14g/d)andcholesterol(‘230mg/d).

Bloodwasdrawnaftera14-hovernightfastbeforeandafter6wkofthelow-energydietsformeasurementsofplasma

glucose

(

16),plasmaimmunoreactiveinsulin

(

17),cholesterol

(

18),high-density-lipoprotein(HDL)-cholesterol,andtriacyl-

glycerolconcentrations

(

19).Nitrogenbalancewasmeasured

comparetheprotein-sparingeffectofthetwolow-energydiets.UrinarynitrogenwasmeasuredbytheKjeldahlmethod(20).

Twenty-four-hoururinesampleswerecollectedeveryweekandaveragedailyurinarylosswascomputedonthebasisof

thesesixcollections.Integumentalandstoollosseswereesti-matedonthebasisofpreviouslyreportedstudies:5and10mg/kgbodywt,respectively(21).Dailynitrogenbalancewascalculatedbysubtractingtotaloutput(urine,stool,andinteg-umentallosses)fromdietaryinput.

Bodyfatcompositionandpercentageofadiposityweredeterminedbytwodifferenttechniques:skinfold-thickness

measurementsatbiceps,triceps,subscapula,andsuprailiac

TABLE1

Physicalcharacteristicsofthesubjects’15%

(F1

Carbohydrate

3M,l9F)

45%

Carbohydrate

6M,1SF)

Age(y)41±945±18Weight(kg)107

23102

Height(cm)162

164

9BMI(kg/m2)41

938

Systolic

BP(mmHg)138

±14136±18DiastolicBP(mmHg)89±985

TABLE

Compositionofdiets’15%Carbohydrate45%Carbohydrate

Energy(kI/d)4214

3154296

320

Carbohydrate

(g/d)37±5115±14

(%)

15±5

45±5

Fat

(g/d)60±530±5

(%)

53±526±5

Protein

(gld)

79±973±5

(%)

32±529±5

‘:

SD.

(22),andbioelectricalimpedanceanalysis(23).Bodycompo-sitionvaluesasassessedbythesetwotechniquesweresignif-icantlycorrelatedandlinear

0.64,

0.0001).

Percent-ageoffatwasexpressedasameanofthesetwomeasurements(skinfoldthicknessandbioelectricalimpedance).

Dataareexpressedasmeans±SEMsandwereanalyzed

withthegeneral-linear-modelsprocedureofSAS(SASInsti-tutemc,Cary,NC).Toevaluatethedifferencebetweenthetwogroupsofobesepatients,beforeandafterweightloss,data

wereanalyzedbytwo-wayanalysisofvariance,withthemul-

tiple-comparisonapproachofScheff#{233}(24,25).

RESULTS

Valuesfortotalbodyweight,bodyfat,waistandhipcir-cumferences,andwaist-to-hipratiobeforethedietsaregivenin

Table4.Thesevalueswerenot

significantlydifferentbe-

tweenthetwogroupsatbaselinenorwasthereasignificantdifferenceintheamountofweightlossinresponsetodiets

containingeither15%or45%carbohydrate.Furthermore,totalbodyfat,waistandhipcircumference,andwaist-to-hipratiodecreasedsignificantlyinbothgroups,andthemagnitudeof

thechangesdidnot

vary

asafunctionofdietcomposition.Thepercentageweightlossandthepercentagefatlossweremore

similarin

thetwogroupsthanweretheabsolutechanges.Dailydietarynitrogenintakewassimilar[12.6±0.3g(15%-carbohydratediet)comparedwith11.7±0.2g(45%-

carbohydratediet)]andnitrogenlosseswerenotsignificantlydifferent[13.9±1.7g(15%-carbohydratediet)comparedwith

11.2±0.9g(45%-carbohydratediet)]betweengroups.The

protein-sparingeffectofbothdietswasequal:nitrogenbalancewas1.3±0.5(15%-carbohydratediet)comparedwith-0.5±

0.6g(45%-carbohydratediet).Nitrogenbalancewasmore

negativewitheachdietduringthefirstweek

F-

.5±

0.2(15%carbohydrate)and

1.8

0.2g(45%carbohydrate)]thanduringthelastSwk.

Table

listsvaluesforfastingplasmaglucose,insulin,

cholesterol,HDL-cholesterol,andtriacylglycerolconcentra-

tionsbeforeandafterthedietaryintervention,andshowsthattheseindexeswerenotsignificantlydifferentbetweenthetwogroupsbeforedieting.Thesedataalsoshowthatfastingplasmaglucose,insulin,cholesterol,HDL-cholesterol,andtriacylglyc-erolconcentrationsdecreasedsignificantlyinpatientseatingthelow-energydiets,whichcontained15%carbohydrate.Al-

thoughtrendsinasimilardirectionwereseenwhenpatientsate

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

TABLE3

ItemizedcompositionofdietsFooditems

DISCUSSION

15%Carbohydrate

Breakfast

Low-fatfreshcheese(20%fat)

Low-fatham

Lunch

Low-fatmeatorfish

Vegetable

Oil

Snack

Low-fat,artificiallysweetenedyogurt

Dinner

Low-fat

meatoreggs

Vegetable

Whole-wheatbread

Oil

Snack

Low-fatfreshcheese(20%fat)45%Carbohydrate

BreakfastLow-fatskimmedmilk(0%fat)Whole-wheatbreadButterormargarineLunchLow-fatmeatorfish

Vegetable

Rice,pasta,orcerealsFruitOil

Snack

Low-fat,artificiallysweetenedyogurt

Dinner

Low-fatmeatoreggs

Vegetable

Rice,pasta,orcerealsOil

SnackLow-fat

freshcheese(20%fat)Fruit

thelow-energydietscontaining45%carbohydrate,themagni-tudeofthedifferenceswasattenuatedandneitherplasmainsulinnortriacylglycerolconcentrationsfellsignificantlyinresponsetothehigher-carbohydratediet.176

GOLAYETALInthisstudyweevaluatedtheeffectsoflow-energydietsthat

Weightvariedsubstantiallyintheirrelativeproportionsoffatand

carbohydrateonbothweightlossandvariousmetabolicend-

points.Theamountofweightlosswassimilarinresponseto150thetwodiets,andwasapparentlyindependentoftheamountof50fatorcarbohydrateinthetwotestdiets,beingrelatedmostcloselytototalenergyintake(Table3).Ontheotherhand,

100

variationsindietarycompositiondidappeartomodifythe100

beneficialeffectsofweightlossoncertainmeasuresofcarbo-

hydrateandlipidmetabolism.Morespecifically,thefallin180fastingplasmaglucose,insulin,cholesterol,triacylglycerol,

andHDL-cholesterolconcentrationswasdecreasedinsubjects

100

eatingalow-energydietrelativelyhighincarbohydrate,and100thechangesinplasmainsulinandtriacylglycerolconcentra-

tionswerenotstatisticallysignificantinthesesubjects.15Toputtheresultsofthecurrentstudyintoperspective,twoissuesmustbeaddressed.Thefirstisapragmaticone,and

involvesthepublicationsofRabastetal(11),whoreportedthatobeseindividualslostmoreweightconsumingdietslowin150carbohydrate,andthatasimpledecreaseindietaryfatintake50canleadtoweightloss.Therearetwocrucialdifferences

betweenourresultsandthoseofRabastetal.First,andprob-

ablymostimportant,thecurrentstudieswereperformedon

100

inpatients,notoutpatients.Second,subjectsinourstudyalso150participatedinprogramsofphysicalexerciseandbothbehav-60ioralandnutritionaleducation.Consequently,webelievethat

100

theresultsofourstudyemphasizeissuesofenergyintakeandoutput,andarelessdependentonvariationsindegreeof180dietarycompliance.

Asecondimportantissuetoaddressistheevidencethatthe100thermiceffectofcarbohydrate(8%)ishigherthanthatoffat

150(4%)(26).Asaconsequenceoftheseconsiderations,ithas60

been

suggestedthatthehighertheratioofcarbohydratetofat,

thelessthetendencytogainweight

(27).Ontheotherhand,the

relevanceofthisinformationtotheeffectoflow-energydiets

1g

mustbequestioned.Forexample,whendietscontaining4.21MJareingested,thethermiceffectof45%ofcarbohydrateis

150J,comparedwithathermiceffectof50Jassociatedwith

eating

15%carbohydrate,ie,a100-idifferenceperday.Thus,

istheoreticallyunlikelythatincreasingtherelativepropor-tionofcarbohydratetofatinhypoenergeticdietswillhaveasignificanteffectontheweightlossthatensuesincompliantpatients.

TABLE4