Similar

Alain Gerald ABSTRACT of diets relative that Golay, Reaven

weight
Anne-Fran#{231}oise

loss with low- or high-carbohydrate
Allaz, Yves Morel, Nicolas de Tonnac, Svetalina Tankova, and

2

The goal were equally

of this study low in energy

was but

to evaluate widely weight

the effect different during in a 4.2 carbo-

lipoprotein energy diets

metabolism consisting

that

followed 15%

the

initiation of energy

of

lowfrom

Downloaded from www.ajcn.org at Univ of Colorado Hlth Sci Ctr Denison Mem Lib on September 30, 2007

of either

or 45%

amounts

of fat and carbohydrate

on body diets

6-wk
persons MJ/d

period
were (1000

of hospitalization.
randomly kcal/d) was assigned composed

Consequently,
to receive of either difference either 32%

43 adult,
containing 15% protein,

obese

carbohydrate. hospitalized
time they also

To increase for the entire
received

dietary duration
behavioral

compliance, of the study,
and nutritional

patients during

were which

education.

hydrate,
fat. There

and 53% fat, or 29% protein,
no significant

45% carbohydrate,
in the amount 15% (8.9
± Furthermore, circumference

and 26%
of weight SUBJECTS AND METHODS

loss in response to diets containing 45% (7.5 ± 0.5 kg) carbohydrate.
creases in total body fat and waist-to-hip

0.6 kg) or
deseen were

significant

in both a function

groups,

and

the magnitude composition.

of the changes Fasting plasma that

did not vary glucose, decreased contained insulin,

as

of diet

cholesterol, and triacylglycerol concentrations cantly in patients eating low-energy diets carbohydrate, but neither plasma insulin nor

signifi15% con-

Forty-three adult, obese patients were studied before and after a 6-wk period of hospitalization. These subjects had been referred to the Obesity Outpatient Clinic of the Department of Medicine at Geneva University Hospital for dietary treatment of their obesity.
During the first visit, it was decided on the basis of a history

triacylglycerol

centrations fell significantly in response to the higher-carbohydrate diet. The results of this study showed that it was energy intake,
nutrient composition, that determined low-energy diets over a short time 1996;63: KEY diet, 174-8. WORDS high-carbohydrate Obesity, diet weight loss, low-carbohydrate weight period. loss

not

of failure to lose weight in response to ambulatory treatment that these individuals would benefit if they were hospitalized for the first 6 wk of treatment. Criteria for admission included
a body mass index (kg/rn2)
>

in response to Am J Clin Nutr

30,

strong

personal

motivation,

and the ability to participate in the requisite amount of physical activity. Patients with obesity secondary to endocrine disease,
as well as those committee Hospital. with psychiatric of the Department diagnoses, were excluded

from

the study.

The protocol

was submitted

to and accepted
at Geneva

by

the ethical University

of Medicine

In addition
structured, INTRODUCTION Although there is little argument that about obesity weight constitutes a activity, niques.

to a low-energy
multidisciplinary education, consisted was of

diet,
program and

subjects
that standard

participated
included behavioral exercise

in a
physical techtraining

nutritional Exercise

1 h of aerobic

health
attention

hazard

(1-4),

there
on how

are widely
to bring

different

opinions
loss

when
in obese proof

per

day

and

1 h of underwater
education provided

physical
by

activity
a registered

per

day.

Nutritional

dietitian

is focused

individuals. When grams it is necessary

evaluating the to differentiate

efficacy of weight-loss between considerations

the relation between changes in energy balance and weight loss (5, 6), the ability of individuals to comply with a weight-loss diet (7), and the long-term success of any weight-loss program
in preventing a return to the original weight reached. lead (8-10). For The first of

twice a week (once in a group session and once individually). The behavioral approach consisted of six sessions, during which issues of self-control, cognitive restructuring reinforcement, and relapse prevention were addressed.
On signed consisted admission to receive of either to the diets 15% hospital, containing or 45% patients 4.2 of Mi/d energy were (1000 as randomly kcal/d) carbohydrate. asthat

these issues this instance,
has loss been and

appears
consensus argued that

to be the most
has low-fat not diets

straightforward,
to better variables proportions to extend in 43 facets obese of

but even
example, weight were of these patients

in
it loss
I

been

From Clinical Address

the

Department

of Medicine,

Geneva

University Medical Treatment Geneva

Hospital, Center,

and Palo

( 1 1), but data from Alford
changes low, present involved in weight and in associated

et al (12)
metabolic

indicate

that both (1200-kcal/d)

weight
similar

Stanford
and

University
Center, reprint

School

of Medicine

and Geriatric
Affairs

Research,

Education

Department requests of

of Veterans to A Golay, University

when
containing drate. tions, changes 174

patients
The

were

prescribed
and was study and

5.0-MJ/d
high initiated

diets
carbohyobservaof the and
Nutr

Alto, CA.
2

Diabetes of

and Teaching Hospital, 1211,

moderate,

Unit, Geneva

Department

Medicine, 14, 1994. October © 1996

14, Switzerland.

a comparison several

Received
Accepted

November
for publication

carbohydrate
Am J Clin

17, American

1995. Society for Clinical Nutrition

1996;63:174-8.

Printed

in USA.

WEIGHT
Baseline listed distribution, characteristics in Table age, 1. The body one diets
foods.

LOSS
experimental

WITH

LOWgroups are of sex

OR

HIGH-CARBOHYDRATE
TABLE Composition

DIETS

I 75

of groups mass of the are

the

two

2
of diets’ 15% Carbohydrate 4214 37±5 15±5 60±5 53±5
± 315

were index,

comparable and blood

in terms pressure.

After
were tions
sisted

baseline
on two
natural

metabolic

data
two shown Recipes A 7-d nutrient

were

acquired,
diets. 2. Both of but from menu meals and among

the

patients
ComposiEnergy (g/d) (kI/d)

45%

Carbohydrate 4296
± 320

started of the
of

experimental in Table and rotational composition of menus

diets used. offered

confood The di-

Carbohydrate
115±14 45±5 30±5 26±5

various was

items menus verse rotation

were foods.

standardized. similar Itemized for the

(%)
Fat

provided menu

(g/d)

compositions low-carbohydrate

I d of the

high-carbohydrate breakfast snack (12%).
(22%),

(%) Protein
(gld)

diets are given Daily energy lunch (33%),

in Table 3. intake was distributed dinner (33%), and

79±9
32±5
±

73±5
29±5

(%)
‘:

Downloaded from www.ajcn.org at Univ of Colorado Hlth Sci Ctr Denison Mem Lib on September 30, 2007

bedtime

The

SD.

total energy and protein contents of the Energy intake was carefully measured subjects present compliance once a week The were during with during instructed each meal the the diet, to eat patients all foods to improve

two diets were similar. for each patient. All and compliance. a l-d These a dietitian To food food was verify record records (22), sition icantly age (skinfold and bioelectrical as assessed and expressed and impedance by these linear (r
=

analysis two 0.64,

(23). P <

Body were

composignifPercent-

values of fat was

techniques two

completed study.

correlated thickness

0.0001).

6 wk of the was

as a mean bioelectrical

of these

measurements

took
count.

the quality
software

and

the quantity
PRODI3+

of food
used

consumed
to calculate

into
tables (15).

acused

impedance).

alimen-

Data
with the

are expressed
general-linear-models

as means

± SEMs
procedure

and

were

analyzed
Insti-

tary plans and food records were from Souci et al (14)

(13). Food composition and Renaud and Attil

of SAS

(SAS

The absolute

amount

of carbohydrate
diet than in the

was three

times

higher
diet

tute mc, Cary, NC). To evaluate the difference groups of obese patients, before and after

between the two weight loss, data

in the 45%-carbohydrate

15%-carbohydrate

were

analyzed

by two-way
approach

analysis

of variance,
25).

with

the mul-

(1 15 ± 14 compared
less in the

with

45%-carbohydrate

37 ± S g), and the amount diet (30 ± 5 compared
similar amounts (‘‘230 mg/d). of

of fat was with 60 ±
saturated fat

tiple-comparison

of Scheff#{233}(24,

5 g). Both diets contained (‘ 14 g/d) and cholesterol

RESULTS Values cumferences, in Table for total body weight, body fat, waist and hip cirgiven be-

Blood was drawn after a 14-h overnight fast before and after 6 wk of the low-energy diets for measurements of plasma glucose ( 16), plasma immunoreactive insulin ( 17), cholesterol ( 18), high-density-lipoprotein (HDL)-cholesterol, and triacylglycerol concentrations ( 19). Nitrogen balance was measured to compare the protein-sparing effect of the two low-energy
diets. (20). Urinary nitrogen was measured by the Kjeldahl method

and 4. These

waist-to-hip ratio values were not

before the significantly

diets are different

tween the two groups at baseline nor was there a significant difference in the amount of weight loss in response to diets
containing body decreased fat, either waist 15% and or 45% hip
vary

carbohydrate. and and of diet groups, percentage

Furthermore, waist-to-hip the fat magnitude loss were composition.

total ratio of The more

circumference, in both as a function and the

significantly

Twenty-four-hour and average daily
these mated mg/kg calculated umental six on body by losses) collections. the basis wt,

urine urinary

samples were collected every week loss was computed on the basis of
and Daily stool losses studies: nitrogen (urine, stool, were 5 and balance and integesti10 was reported output input.

the changes
percentage
similar in

did not
weight

loss

Integumental of previously (21). total dietary respectively

the two groups Daily dietary nitrogen (1 5%-carbohydrate diet)

than were the absolute changes. intake was similar [12.6 ± 0.3 g compared with 1 1 .7 ± 0.2 g (45%were not significantly diet) compared with

subtracting from

carbohydrate diet)] and nitrogen losses different [13.9 ± 1.7 g (15%-carbohydrate

Body fat composition and determined by two different
measurements at biceps, triceps,

percentage techniques:
subscapula,

of adiposity were skinfold-thickness
and suprailiac

1 1 .2 ± 0.9 g (45%-carbohydrate
protein-sparing was 1 .3 ± 0.5 effect of both diets (15%-carbohydrate

diet)]
was diet)

between
equal: compared

groups.
with -0.5

The
±

nitrogen

balance

0.6
TABLE Physical 1 characteristics of the subjects’ 15%
(F1

g (45%-carbohydrate
each and diet
-

diet).
during

Nitrogen

negative with carbohydrate)
45% (n Carbohydrate

1 .8

±

the first 0.2 g (45% fasting

balance week F- I .5

was
± 0.2

more
(15% than

carbohydrate)] glucose, and

Carbohydrate

during the last S wk. Table 5 lists values

for the

plasma intervention,

insulin,

3M,
41±9

l9F)

6M,
45±18 102 ± 164 136

1SF)

cholesterol,
tions before

HDL-cholesterol,
and after dietary

and

triacylglycerol

concentrashows that

Age(y) Weight Height BMI
Systolic

(kg) (cm)

107 ± 23 162 41 (mm BP, Hg) blood pressure.
±

18

9

± 9

(kg/m2)

± 9

38 ± 5 ± 18 14 85 ±

these indexes were not significantly different groups before dieting. These data also show glucose, insulin, cholesterol, HDL-cholesterol, erol concentrations the low-energy diets, decreased which significantly contained 15%

between the two that fasting plasma and triacylglycin patients carbohydrate. eating Al-

BP (mm Hg)
BP

138 ± 14
89 ± 9

Diastolic

iE ± SD.

though

trends

in a similar

direction

were

seen when

patients

ate

176 TABLE
Itemized

GOLAY
3
composition Food of diets items

ET AL
DISCUSSION

In this study
Weight
g

we evaluated
in their

the effects
relative

of low-energy
proportions of

diets
fat

that
and

varied

substantially

15% Carbohydrate
Breakfast

carbohydrate
points. The

on both
amount was

weight
of weight apparently in the two

loss
loss

and
was

various
similar

metabolic
in response

endto

Low-fat
Low-fat
Lunch

fresh
ham meat

cheese

(20%

fat)

150 50
100

the two diets, and fat or carbohydrate closely variations

independent test diets,

of the amount of being related most the other hand, to modify the

Low-fat

or fish

to total energy intake (Table 3). On in dietary composition did appear

Vegetable
Oil
Snack

100

beneficial
hydrate

effects
and plasma lipid

of weight
metabolism. glucose,

loss on certain
More

measures

of carbothe fall in

specifically,

Low-fat,
Dinner

artificially meat or eggs bread

sweetened

yogurt

180
100

fasting

insulin,

cholesterol,

triacylglycerol,

Downloaded from www.ajcn.org at Univ of Colorado Hlth Sci Ctr Denison Mem Lib on September 30, 2007

and HDL-cholesterol 100
25

concentrations

was decreased

in subjects

Low-fat
Vegetable

eating a low-energy diet relatively high in carbohydrate, and the changes in plasma insulin and triacylglycerol concentrations were not statistically significant in these subjects. To put the results of the current study into perspective, issues must be addressed. lost more The of Rabast weight first is a pragmatic consuming diets one, reported low two and that in

Whole-wheat

Oil
Snack Low-fat 45% Carbohydrate fresh cheese (20% fat)

15

50

involves obese

the publications individuals to

et al (1 1), who

Breakfast Low-fat skimmed milk (0% fat) Whole-wheat bread Butter or margarine Lunch Low-fat meat or fish
Vegetable

150 50
5

carbohydrate, can lead

and that a simple weight loss. There

decrease in dietary are two crucial

fat intake differences

between

our results

and those

of Rabast

et al. First,

and prob-

100

Rice, Fruit Oil
Snack

pasta,

or cereals

150 60
100

ably most important, the current studies were performed on inpatients, not outpatients. Second, subjects in our study also participated in programs of physical exercise and both behavioral and nutritional education. Consequently, we believe that the results of our study emphasize issues of energy intake and output, and are less dependent on variations in degree of

Low-fat,
Dinner

artificially meat or eggs

sweetened

yogurt

180

dietary

compliance.

A second 100
150 60
5 fresh cheese (20% fat)

important

issue

to address (8%)
of these the ratio weight to the
(27).

is the evidence is higher than that
considerations, of carbohydrate
On the other

that the of fat
it has to fat,
hand, the

Low-fat
Vegetable

thermic
(4%)

effect
(26). As suggested

of carbohydrate
a consequence that the higher to gain information For the thermic

Rice, Oil

pasta,

or cereals

been

the less relevance must MJ are

the tendency of this

Snack Low-fat
Fruit

1g
1 45% carbohydrate, and fell the magnineither plasma significantly in

effect when of 45%

of low-energy diets containing of carbohydrate per relative diets ensues will day.

diets 4.2 is

be questioned. ingested,

example, effect ie, a 100-i that weight

150 J, compared with eating 15% carbohydrate,
the low-energy diets containing it is theoretically tion of carbohydrate effect on significant patients. tude of the differences insulin nor triacylglycerol response to the was attenuated concentrations diet.

a thermic

effect
increasing loss

of 50 J associated
difference the

with
Thus, proporhave a

unlikely to fat the

in hypoenergetic that

in compliant

higher-carbohydrate

TABLE 4 Body composition

before

and after weight

loss’ 15% Carbohydrate Before After
99 ± 8.3
42

45% Carbohydrate Before
102
-

After
95 ±
32

Total body weight Weight loss (%)
Body fat (kg)

(kg)

107
-

± 5

± 4

± 0.5

7.4 ± 0.6
±

47 ± 3
-

38 ± 22 17.7 ± 104
±

41
-

2

34 ± 22

Fat loss (%)
Waist circumference (cm)

1.0
32

16.8
± 3

± ±

1.2
32

1 15 ± 4

1 13 0.93

103 0.91

Hipcircumference(cm) Waist-to-hip ratio
i ± SEM. 2--I Significantly

126±4
0.91
± 0.02

117±32 0.88 ± 0.0l

121 ±2
± 0.02

112±22
± 0.02

different

from

b efore

weight

loss:

2

p <

0.001,

-‘

P < 0.01,

p

<

0.05.

WEIGHT
TABLE
Biochemical 5 indexes before and after weight

LOSS

WITH

LOW-

OR

HIGH-CARBOHYDRATE

DIETS

177

loss’ 15%

Carbohydrate After
4.4 57.6 4.5 ± 0.12 ± 6.62
± 0.22

45% Carbohydrate Before
5.4 ± 0.3 96.0 ± 13.2 5.0 88.2 5.3

Before Plasma Plasma Plasma Plasma
Plasma
‘ 2-4

After
± 0.2 ± 9.6
± 0.3?

glucose (mmolIL) insulin (pmol/L) cholesterol (mmol/L) HDL cholesterol (mmoLfL)
triacylglycerol ± SEM.
Significantly different from before weight loss:

5.3 ± 0.2 106.8 ± 15.6
5.7
± 0.3

6. 1
11

± 0.4

1.1 ± 0.1
1.7 ± 0.1

0.9 ± 0.12 1.4 ± 0.l

± 0.1
± 0.2

1.0 ± 0.l 1.8 ± 0.2

(mmolIL)

2.2

2

p <

0.001,

p <

0.01,

p <

o.os.
Downloaded from www.ajcn.org at Univ of Colorado Hlth Sci Ctr Denison Mem Lib on September 30, 2007

In weight diets

conclusion, loss can as inpatients,

our occur and

results when that of the Indeed, by the to this

emphasize subjects effect,

that consume as shown

substantial low-energy by Alford

induced-thermogenesis relapse of obesity.
7. Lichtmann
self-reported

in overweight patients: mt I Obes 1989;13:767-75.
Pisarka
actual

a factor

contributing
between
subjects.

to

SW,
and I Med

P, Berman
caloric intake

ER,
and

et al.
exercise

Discrepancy
in obese

et al (12), is independent fat and carbohydrate. the kind of low-fat, advocated maintenance tion Program insulin and likely insulin related and the

relative proportion of dietary if anything, consumption of diets Cholesterol the for weight Educa8.

N Engl Dwyer

1992;327:l893-8.

high-carbohydrate National minimize concentrations.

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lB Lippincott

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Co. 1992:662-76. 9. Wing RR, leffery RW. Outpatient treatments of obesity: a comparison of methodologies and clinical results. Int I Obes 1979;3:26l-79. 10. Van Itallie TB. Diets for weight reduction: mechanism of action and
physiological weight I 1. Rabast
in obese

effects. London:

In: Bray Iohn KH, EhI

G, ed. Obesity: Libbey, M. Loss
or low

comparative sodium
diet.

methods and
Ann

of water
Nutr

portion
tion, decrease low-fat, servation

to dietary

carbohydrate
in loss women diet was

consumption
has consuming (30). Given similar when

(29).
been

In addishown to

control.

1980:15-21. of weight,
carbohydrate

HDL-cholesterol significantly high-carbohydrate that weight

concentration

U, Vornberger
persons consuming 1981 ;25:342-9.

a low-energy, the current obobese subjects fat to
13. 14. 12.

a high

Metab
Alford

BB,

Blankenship protein and

AC, fat

Hagen content

RD. of

The the

effects diet

of variations upon weight

in loss,

ate low-energy and carbohydrate diets that are

diets, irrespective of the proportion of in these diets, and the fact that low-energy low in fat and high in carbohydrate lead in insulin and lipid diets, it seems dietary diets approach. will this have diet, view low-fat metabolism reasonable Although a better compared to question

carbohydrate,

blood
Assoc Kluthe
vises.

values

and nutrient
3+.

intake

of adult
logical for

obese
food 1989. of food

women.

I Am Diet ad1989/

1990;90:534-40. B. Prodi
Switzerland:

smaller changes with low-carbohydrate the advocacy that suggested

Interactive
University of

and nutritional
composition

Freiburg,

of this

it is often long-term of

Souci

SW,

Fachmann

W,

Kraut

H. Tables

benefit with a weight-maintenance persuasive data in support of diet. Until reasonable composition, low-energy such information to suggest that that diets. determines

we are unaware with a weight-loss available, intake, loss in it not response seems energy

becomes it is energy weight

1990. (La composition des aliments. Tableaux des valeurs nutritives 1989/1990.) Stuttgart, Germany: Ed Wissentschaftliche Verlagsgesellschaft mbH, 1989 (in German). 15. Renaud 5, Attil MC. Tables of food composition. (La composition des aliments.) Paris: Astra-Calv#{233}Information Lipodi#{233}t#{233}tique, INSERM
unite 63, 1986 AH, Clin (in French). Litle RL, Sternberg IC. A new and rapid method consumpcharcoal PC. Clin Enzymatic Chem imfor of glucose Chem V, Lau CA, Poon KS, LS, of by measurements CW, ES, serum Bleicher Richmond of rate of oxygen SI. W, Coated Fu 16. Kadish tion. 17. 18. Herbert

to

U
of the dietary staff of the Department P Rigoli, C Bussien, of especially T Lehmann,

determination

We are grateful
Medicine and for their I Duffey.

to the members assistance,

1968;14:1l6-31. Gottlieb Chang total

munoassay
Allain determination

of insulin.

I Clin Endocrinol

l965;25:1375-84.
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