ESPEN Congress Brussels 2005

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1 ESPEN Congress Brussels 2005 Low carbohydrate or low fat diet to loose weight: Pro Low Fat Diets Arne Astrup

2 27th ESPEN Congress 28 August 2005 Low carbohydrate or low fat diet to loose weight: Pro Low Fat Diets Arne Astrup Head, professor, MD, dr.med.sci. Institute of Human Nutrition

3 Diets and obesity Hypocaloric reduced-fat diets for weight loss Reduced-fat diets for maintenance Role of non-fat component Low-carbdiets High protein, normal fat diets Conclusions

4

5 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)

6 Changes in body weight Moderate fat Low fat group group (n=312) (n=336) Before kg) (16.0)( (16.9) After (kg) 94.1 (15.4) 93.3 (16.1)( ns Decrease (kg) 6.6 (3.5)( 6.9 (3.4) ns Petersen M, Taylor M, Saris W, Verdich C, Toubro S, MacDonald I, Sørensen, TIA, Astrup A. IJO (In press)

7 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)

8 Results lipids, glucose and insulin moderate (n=312) and low-fat group (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 ( ) Total TAG (mmol/l) 0.04 (0.41) 0.19 (0.71) (-0.16 (-0.03)) LDL Chol (mmol/l) 0.26 (0.57) 0.14 (0.50) 0.11 ( ) HDL Chol (mmol/l) 0.08 (0.18) 0.04 (0.16) 0.04 ( ) Insulin (µu/ml) 1.2 (4.9) 1.2 (5.9) 0.3 ( ) Glucose (mmol/l) 0.12 (0.49) 0.14 (0.48) ( ) Petersen M, Taylor M, Saris W, Verdich C, Toubro S, MacDonald I, Sørensen, TIA, Astrup A. IJO (In press)

9 A typical long-term randomised ad lib Low-fat diet study Change in weight (kg) 3 0 Low adherence a A reduction in dietary fat from 35% ** to 25% of total -3 energy produced a High adherence mean weight loss of ** ** ** 3.3 kg after one year -6 0 Intervention Years Swinburn et al. Diabetes Care 2001; 24:

10 3 Meta-analysis analysis of low-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 relationship between dietary fat-% and weight loss

11 The Lifestyle Heart Trial 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 kg (no difference in physical activity) Less than half coronary events Ornish et al. Lancet 1990; 336: Ornish et al. JAMA 1998; 280:

12 Adverse effect of low-fat diets The non-fat component Carbohydrates sugar GI - soft drinks Protein Metabolic symdrome - inflammation

13 CARMEN Change in body weight ² weight (kg) p<0.05 p<0.001 SCHO CCHO CD CS group Saris, Astrup, Prentice et al. Int J Obes

14 The importance of the non-fat component Raben et al. Am J Clin Nutr 2002; 76: 721-9

15 Does sugar in soft drinks make you fat? Sugar versus sweetener Weight changes Kg 2,5 1,5 Sucrose Sweetener 20 % increase in TG in sucrose group vs. Control (AJCN in press) 0,5-0,5-1,5 Group x time, p < , Weeks Raben et al. Am J Clin Nutr 2002; 76: 721-9

16 Low-fat vs. Low-fat plus Gardner et al. Ann.Int.Med. 2005,145:725-9

17 Berry - Lancet The diet: < 30 % fat g fruit g vegetables g walnuts/almonds g whole grain Produced a 3 kg weight loss over 2 years Singh et al. Lancet 360, 1455,2002

18

19 Diabetes Prevention Program: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Goals for lifestyle treatment: 7 % weight loss ( maintained ) 25 E % from fat kcal/day 150 min brisk walking/ week 16 sessions over 6 months, subsequently one session/month. Age 51 yr; BMI 34 kg/m 2 ; average follow-up 2.8 yr; average weight loss 7% after 1 yr and 5% for study duration

20 Figure 14: Successful weight loss with a hypo caloric-low fat diet and increased physical activity (n=3234) Weight loss (kg) Placebo Year of treatment Metformin Lifestyle

21 Figure 15: Reductions in the incidence of diabetes with a hypo caloric-low fat diet and increased physical activity Cumulative incidence of diabetes (%) Placebo Metformin Lifestyle RR* 31% RR* 58% Year of treatment *Reduction in risk of progressing to type 2 diabetes versus placebo

22 CRP predicts adverse effect on TG of 6 months high simple-cho diet a, b, c, d a b c d Sim ple CHO Com plex CHO Control Brinkman Sørensen et al. (2004)

23 Diets and obesity Hypocaloric reduced-fat diets for weight loss Reduced-fat diets for maintenance Role of non-fat component Low-carbdiets High protein, normal fat diets Conclusions

24 Popular high-protein diet books

25 Low Carbohydrate vs Low Fat (Completers analysis) 0 Weight Loss (%) Low-Fat Low Carb Foster et al NEJM 2003; Months of Diet

26 Very similar weight loss, but higher drop-out in Ornish and Atkins

27 RDI: At least 130 g carbohydrate/day Atkits: g/d Adverse effects: Muscle cramps, headache, weakness, diarheea etc. Astrup, Larsen, Harper. The Lancet. 2004; 364:

28 Low-carb and physical performance

29 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): SEP 2005

30 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

31 Energy density does matter Potatoes 450 g (3.6 kj/g) Avocado 260 g (7.7 kj/g)

32 Diets and obesity Hypocaloric reduced-fat diets for weight loss Reduced-fat diets for maintenance Role of non-fat component Low-carbdiets High protein, normal fat diets Conclusions

33 Proposed Hierarchy of Satiety Need hypothesis-driven studies to determine differences Protein leucine fructose fiber Carbohydrate mct sucrose Fat

34 Can more protein as part of a normal-fat diet improve weight loss? or

35 A randomized 6-month 6 trial on two fat-reduced diets: High CHO versus high protein High adherence can be achieved by providing all foods free of charge Skov AR et al. Int J Obes 2002; 23:

36 DIETARY INTAKE Baseline 0-6 mo 12 mo (n=50) P (n=46) P (n=41) P Energy (MJ/d) MP 9.9 (±0.5) NS 10.8 (±0.4) (±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) < (±0.4) < 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) < (±1.8) 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 group Due A et al. Int J Obes 2004;28:

37 A randomized 12-month trial on two fat-reduced diets: High CHO versus high protein Urinary Nitrogen excretion 18 (n=23) Medium-protein High-protein Control 16 (n=23) 24-h UN (g) (n=14) (n=22) (n=18) Duration (month) Due, Toubro, Skov & Astrup, Int J Obes (in press)

38 A randomized 12-month trial on two fat-reduced diets: High CHO versus high protein Weight loss and fat loss Skov AR et al. Int J Obes 2002; 23:

39 Protein reduces Intra-abdominal fat (cm²) P= P=0.03 Medium-protein High-protein

40 Conclusions Intervention studies have shown that replacement of carbohydrate by protein from meat and dairy products (<25% E) in ad libitum consumed fatreduced 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!

41 US recommendations AMDR (DRI, Institute of Medicine, USA) Protein: Adults: 10-35% Older children: 10-30% Smaller children: %

42 Diet, Obesity and Genes European Commission 6 th framework: Food Quality & Safety Coordinator: Wim Saris (NUTRIM, Maastricht)

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