espen congress brussels 2005 · espen congress brussels 2005 low carbohydrate or low fat diet to...

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


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

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


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).


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)



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


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


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


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


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


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)

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.


Low-carb and physical performance


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


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


Energy density does matter

Avocado 260 g

(7.7 kJ/g)

Potatoes 450 g(3.6 kJ/g)


Proposed Hierarchy of SatietyNeed hypothesis-driven studies to determine differences

Protein

Carbohydrate

Fat

fiber

sucrose

mct

fructose

leucine


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


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.


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)


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


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


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 !


US recommendations

• AMDR (DRI, Institute of Medicine, USA)Protein:

• Adults: 10-35% • Older children: 10-30%• Smaller children: 10-20 %


Diet, Obesity and Genes

European Commission 6th framework: Food Quality & SafetyCoordinator: Wim Saris (NUTRIM, Maastricht)

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