**COMMENTS OF MICHAEL B. ZEMEL, Ph.D.**

**In response to the call for comments with respect to obesity**

**To the Division of Dockets Management (HFA-305), Food and Drug
Administration**

**CFR October 8, 2003 (Volume 68, Number 195, pages 58117-58118)**

My name is Michael B. Zemel. I serve as a Professor in the Departments
of Nutrition and Medicine at the University of Tennessee and as the
Director of the University of Tennessee Nutrition Institute. You have
asked for comments on six questions specific to developing solutions to
the obesity epidemic in the US, and I would like to address my response
to questions 3 (available evidence to guide effective public efforts for
the prevention and treatment of obesity) and 5 (opportunities for the
development of healthier foods/diets and what research might support
these efforts).

We all understand that thermodynamics and energy balance comprise the
core of the obesity epidemic, with small increases in energy intake
coupled with minimal physical activity resulting in net energy storage
and slow weight gain over time. While there can be little doubt that it
is of prime importance to address these issues of energy intake and
energy output, I would like to instead address my comments to
nutritional strategies which may alter nutrient and energy partitioning,
potentially resulting in reductions in the risk of overweight and
obesity. We know from previous experience the value of promoting
positive behaviors versus trying a prohibitive approach to accomplish a
given health outcome. For example, although there is a well established
relationship between salt intake and blood pressure control, inability
of most patients to comply with highly sodium restricted diets presents
a nearly overwhelming barrier to the success of these diets. In
contrast, the DASH ([D]{.underline}ietary [A]{.underline}pproaches to
[S]{.underline}top [H]{.underline}ypertension) diet presents the
positive approach of increasing fruit, vegetable and dairy intake to
lower blood pressure, and numerous studies now attest to the relative
success of these less restrictive dairy-rich and/or DASH-based diets in
the control of blood pressure^1-3^. Notably, recent evidence now
indicates that these same diets play significant role in the disposition
of dietary energy and may be helpful in the prevention and management of
obesity.

A substantial body of evidence has emerged over the last three years in
support of an "anti-obesity" effect of dietary calcium and dairy
products. Increasing dietary calcium in the absence of energy
restriction appears to result in a re-partitioning of dietary energy
from adipose tissue to lean body mass, resulting in a net reduction in
fat mass. Furthermore, increasing dietary calcium intake during energy
restriction results in a marked augmentation of body weight loss and fat
loss in both mice and humans (reviewed in ^4^; ^5-9^). Notably, when
dairy is the source of the calcium, these effects are more pronounced,
suggesting that additional components of dairy contribute to this
effect. These findings are supported by epidemiological observations
from NHANES III^5^ , The Quebec Family Study^10^, The Continuing Survey
of Food Intake by Individuals^11^, the CARDIA study^12^, and the
HERITAGE Family Study^13^. Moreover, mechanistic studies demonstrate
logical mechanisms for these effects (reviewed in note ^4^).

Overall, the available evidence indicates that inclusion of three
servings of dairy into the daily diet results in reductions in body fat
of approximately 5% and improvements in metabolic profiles. Moreover,
when coupled with modest caloric restriction, this dietary pattern
augments the weight and fat loss secondary to caloric restriction by as
much as 70%, and increases the fraction of fat that is lost from the
trunk region in comparison with comparable calorie restriction in
individuals on low dairy intakes^4,\ 5,\ 7-9^.

Accordingly, it seems likely that the prevailing low intake of
calcium-rich foods plays a contributory role in the current obesity
epidemic. Consequently, it would appear to be appropriate to stress the
importance of achieving recommended levels of calcium and dairy foods in
the diets of individuals seeking to lose weight and/or to avoid
inappropriate weight and fat gain; broad application of this strategy to
the US population has significant potential to help combat the obesity
epidemic while still remaining consistent with other broad nutritional
recommendations for the maintenance of optimal health.

Notes

1.  McCarron DA, Reusser ME. Finding consensus in the dietary
    calcium-blood pressure debate. *J Am Coll Nutr*. 1999;18: 398s-405s.

2.  Appel LJ, Moore TJ, Obarzanek E, et al. For the DASH Collaborative
    Research Group: A clinical trial of the effects of dietary patterns
    on blood pressure. *N Engl J Med*. 1997;336: 1117-24.

3.  Svetky LP, Simons-Morton D, Vollmer WM, et al. For the DASH Research
    Group: Effects of dietary patterns on blood pressure. Subgroup
    analysis of the Dietary Approaches to Stop Hypertension (DASH)
    randomized clinical trial. *Arch Intern Med*. 1999;159: 285-93.

4.  Zemel MB. Role of dietary calcium and dairy products in modulating
    adiposity. *Lipids* 2003; 38:139-146.

5.  Zemel MB, Shi H, Greer B, DiRienzo D and Zemel PC. Regulation of
    adiposity by dietary calcium. *FASEB J.* 2000; 14:1132-1138.

6.  Heaney RP. Normalizing calcium intake: Projected population effects
    for body weight*. J Nutr* 2003; 133:268S-270S.

7.  Zemel B, Nocton AM, Richards J, Milstead A, Gebhardt. Campbell PJ
    Increasing dairy calcium intake reduces adiposity in obese
    African-American adults. *Circulation* 2002; 106 (suppl 2) II-610.

8.  Zemel MB, Thompson W, Zemel P, Nocton AM, Milstead A, Morris K,
    Campbell P. Dietary calcium and dairy products accelerate weight and
    fat loss during energy restriction in obese adults. *Am J Clin Nutr*
    2002; 75 (2S):342S.

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9.  Zemel MB, Nocton AM, Richards JD, Russell SM, Milstead AM, Gebhardt
    LP. Dairy (yogurt) augments fat loss and reduces central adiposity
    during energy restriction in obese subjects. *FASEB J*.
    2003;A1088:679.3.

10. Jaqumain M, Doucet E, Despres J-P, Bouchard C, Tremblay A. Calcium
    intake, body composition, and lipoprotein-lipid concentrations in
    adults. *Am J Clin Nutr* 2003; 77:1448-1452.

11. Albertson AM, Good CK, Holschuh NM, Eldridge EL. The relationship
    between dietary calcium intake and body mass index in adult women:
    Data from the Continuing Survey of Food Intake by Individuals,
    1994-96. FASEB J 2003; 17:A289.

12. Pereira MA, Jacobs DR, Van Horn L, Slattery ML, Kartashov AI, Ludwig
    DS: Dairy consumption, obesity, and the insulin resistance syndrome
    in young adults. The CARDIA study. *JAMA* 2002; 287:2081-2089

13. Loos R, Rankinen T. Leon A, Rao DC, Skinner J, Wilmore J,
    Bouchard C. Calcium intake and body composition in the HERITAGE
    family study. Obesity Res 2003; 11:A145.