# Presentation: 648743

## Research on Nutritional Contributors to Obesity

- Neal D. Barnard, M.D.
- Physicians Committee for Responsible Medicine
- 5100 Wisconsin Avenue NW, Suite 400
- Washington, DC 20016

## Obesity in the U.S. and JapanBMI ≥ 30

- 	Yoshiike N. Obes Rev 2002;3:183-90. 	Flegal KM. Int J Obesity 1998;22:39-47.

-         United States
- Japan

- %

- 		    1960	         1971-         1976-        1988-        1999-		                        1974           1980         1994          2000

## Obesity in the U.S. and JapanBMI ≥ 30

- 	Yoshiike N. Obes Rev 2002;3:183-90. 	Flegal KM. Int J Obesity 1998;22:39-47.

-         United States
- Japan

- %

- 		    1960	         1971-         1976-        1988-        1999-		                        1974           1980         1994          2000

## Overweight in U.S. and Japan

- 	Yoshiike N. Obes Rev 2002;3:183-90. 	Flegal KM. Int J Obesity 1998;22:39-47.

- BMI 25–29.9 kg/m2

- U.S.

- Japan

- %

- %

- %

- %

- %

## Overweight and Obesity in Japan

- 	Yoshiike N. Obes Rev 2002;3:183-90. 	Yoshiike N. Asia Pac J Clin Nutr 2002;11(Suppl 8):S727-31.

-         BMI 25-29.9
- BMI ≥ 30

- %

- %

- %

- %

- %

- %

- %

- Prevalence in Men

## Falling Carbohydrate Intake in Japan

**	****Murata M. Am J Clin Nutr 2000;72(suppl):1379S-83S.**

- 		1955	     1965        1975       1985      1994

## Rising Fat Intake in Japan

**	****Murata M. Am J Clin Nutr 2000;72(suppl):1379S-83S.**

- 		1955	        1965           1975           1985         1994

## Dietary Patterns and Obesity

**Asia**
- Grain-Centered Diet
- Obesity Is Rare

**U.S., Prior to 1980**
- Meat-Centered Diet
- Obesity Is Common

**U.S. After 1980**
- Meat-Centered Diet + Extra Calories
- Obesity Is an Epidemic

## Differential Roles for Carbohydrate

**Asia**
**Carbohydrate-rich foods are staples: **
**Rice**
**Starchy vegetables**
**Noodles **

**U.S.**
**Carbohydrate-rich foods are vehicles for dietary fat: **
**Toast and butter **
**Potatoes and gravy**
**Spaghetti and meat**
**Pizza and cheese **

## A Randomized, Controlled Study of the Effect of a Low-Fat, Vegan Diet on Body Weight and Metabolism in Postmenopausal Women

**Neal D. Barnard, M.D., Anthony R. Scialli, M.D.,**
**Gabrielle Turner-McGrievy, M.S., R.D.,**
**Amy J. Lanou, Ph.D., Jolie Glass, M.S.**
**Funded by the Cancer Project of the Physicians Committee for Responsible Medicine**

## Methods

**59 overweight (BMI 26-44 kg/m****2****) postmenopausal women**
**Randomly assigned to a low-fat vegan or control diet**
**Exercise levels held constant**
**Data collected at baseline and 14 weeks**

## Diets

**Low-Fat, Vegan Diet**
**Grains, vegetables, legumes, and fruits**
**No limit on energy intake or portion sizes**
**Excluded animal products, oils, high-fat plant foods**
**~10% of energy from fat, 15% from protein, and 75% from carbohydrates**
**Control Diet**
**NCEP Step II guidelines**
**No limit on energy intake**
**Meat intake **_**<**_** 6 ounces/day and fat grams **_**<**_** 60 per day**
**Total fat limited to 30% of energy**
**~15% of energy from protein and > 55% from carbohydrates**

## Nutrient Intake 

*** P = 0.05**
**** P < 0.05**
**For comparison of low-fat vegan versus control diet changes (baseline to 14 weeks).**

## Fiber Reduces Calorie Intake

- Every 14 grams of fiber in the daily diet
- reduces energy intake by approximately 10%.

## Vegan Diet vs. NCEP Step II Diet

## Vegan Diet vs. NCEP Step II Diet

## Vegan Diet vs. NCEP Step II Diet

## Changes in Body Compositionand Metabolism 

**** P < 0.05**
**For comparison of low-fat vegan versus control diet changes (baseline to 14 weeks).**

## Insulin Sensitivity

**We found an average 24% increase in insulin sensitivity in the vegan group, with no significant change in this variable in the Step II group.**

**Lanou A, ****Scialli AR****, ****Turner-McGrievy**** G, Glass J. Unpublished Data. 2003.**

## Fat Content(Percentage of Calories from Fat)

-  Leanest beef				29%
-  Skinless chicken breast		23%
-  Sea trout					32%
-  White tuna				16%
-  Broccoli					8%
-  Beans 					4%
-  Rice					1–5%
-  Potato					1%

## Slide 21

## Slide 22

## Slide 23

## Slide 24

## Casomorphins

- Opiates that form as casein (milk protein) is digested.

## Casomorphins

- From ß-casein:

| ß-casomorphin-7 | Try-Pro-Phe-Pro-Gly-Pro-Ile |
| --- | --- |
| ß-casomorphin 5 (bovine) | Tyr-Pro-Phe-Pro-Gly |
| ß-casomorphin 5 (human) | Tyr-Pro-Phe-Val-Glu |
| Morphiceptin | Tyr-Pro-Phe-Pro-NH2 |

- From as1-casein:

| a-Casein exorphin | Arg-Gly-Phe-Gin-Asn-Ala |
| --- | --- |

- Shah NP. Br J Nutr 2000;84(suppl 1):S3-S10.Teschemacher H. J Dairy Res 1986;53:135-8.

## Super-Sizing, 1977–98 (U.S.)

**	****Nielsen SJ. JAMA 2003;289:450-3.**

**                ****Soft              Fruit             Ham-           Cheese-****              Drinks          Drinks          burgers          burgers**

## U.S. Cheese Intake Has Doubled

## Slide 29

## Slide 30

## Slide 31

## The U.S. Government at Work

**2.25 million pounds of cheese**
**380 tons of fat **
**1.2 tons of pure cholesterol**
- USDA Report to Congress on the Dairy Promotion Programs, 2000** **

## The U.S. Government at Work

**Subway’s “****Chicken Cordon Bleu,” “Honey Pepper Melt”**
**Pizza Hut’s “Ultimate Cheese Pizza”**** **
**Burger King, Taco Bell**
- USDA Report to Congress on the Dairy Promotion Programs, 2000

## USDA Report to Congress on the Dairy Promotion Programs, 2000 

|  |  |
| --- | --- |
|  |  |

- Dick Cooper, Vice President of Cheese Marketing, Dairy Management, Inc., at the “Cheese Forum,” December 5, 2000.
- USDA Report to Congress on the Dairy Promotion Programs, 2000** **

## Slide 35

## BMI of Meat-Eaters and Vegetarians

**	****Appleby PN. Int J Obes 1998;22:454-60.**

**Oxford Vegetarian Study (age-adjusted means)**

**Male Meat-Eaters****	****	****23.2 kg/m****2**
**Male Non-Meat-Eaters****	****22.1 kg/m****2**
**Female Meat-Eaters****	****	****22.3 kg/m****2**
**Female Non-Meat-Eaters****	****21.3 kg/m****2**

- All participants were non-smokers.

- N = 2,445 meat-eaters,  2,287 non-meat-eaters

## Loma Linda Study

**	****Haddad. Am J Clin Nutr 1999;70(suppl):586S-93S.**

- Mean Age (years)			33.5			36.0Mean BMI (kg/m2)			25.5			20.5

**      ****Non-Vegetarians (20)         Vegans (25)**

- Bread (servings)			10.9			11.7Vegetables (servings)			1.4			3.3Fruit (servings)			2.6			5.6Legumes (1/2 cup servings)		0.3			1.2Nuts and seeds (ounces)		0.2			0.9Meat (ounces)				6.3			0Milk (cups)				0.9			0

**Diet Characteristics**

## Loma Linda Study

**	****Haddad. Am J Clin Nutr 1999;70(suppl):586S-93S.**

-                Bread       Vegetables        Fruit          Legumes        Nuts &          Meat           Milk            (servings)    (servings)      (servings)     (1/2 cup           Seeds        (ounces)     (ounces)			                                 servings)      (ounces)

- Non-Vegetarians (20)  Mean Age — 33.5 yearsMean BMI — 25.5 kg/m2

- Vegans (25)Mean Age — 36.0Mean BMI — 20.5 kg/m2

- =

- =

## Dangers of Low-Carbohydrate, High-Protein Diets

|  |  |
| --- | --- |
|  |  |

## Low-Carbohydrate, High-Protein (“Atkins”) Diet

| Induction Phase=20 grams carbohydrate
 |  |
| --- | --- |
| Excluded:FruitStarchy vegetablesLegumesGrainsMilkAlcoholCaffeine
 | Permitted:MeatsEggsCheese (3-4 oz.)Nonstarchy vegetables
Salad vegetables 
(3 cups maximum for all vegetables) |

## Low-Carbohydrate, High-Protein (“Atkins”) Diet

| Transition Phases (“Ongoing Weight Loss,” “Pre-Maintenance”)
Slowly increase carbohydrates until weight loss stalls.
 |
| --- |
| 
Maintenance PhaseMaintain carbohydrate restriction for life. |

## Nutrient Analysis of Atkins Sample Menus

- Nutrient intakes are based on *Dr. Atkins’ New Diet Revolution* (M. Evans & Co., 1999), using Nutritionist V., Version 2.0, for Windows 98 (First DataBank, Inc., Hearst Corporation, San Bruno, CA).

**	****	****	****	****         ****Atkins****	****	****	****Atkins****	****	****	****	****        Induction****	****       Maintenance**
- Energy, kcal				1759			2173Protein, g (% energy)		143 (33%)		135 (25%)Carbohydrate, g (% energy)	15 (3%)		116 (22%)Fat, g (% energy)			125 (64%)		110 (45%)Saturated fat, g			42			38Cholesterol, mg			886			834Fiber, g				2			18

## Initial Weight Loss on Low-Carbohydrate Diets

- Water loss:
- 1 pound of glycogen holds 3 pounds of water

## Fiber (grams)

- Atkins Diet nutrient intakes are based on *Dr. Atkins’ New Diet Revolution* (M. Evans & Co., 1999), using Nutritionist V., Version 2.0, for Windows 98 (First DataBank, Inc., Hearst Corporation, San Bruno, CA).

-                **Low-Fat ****	****   Pyramid             Atkins              Atkins****                Vegan                                     Induction      Maintenance**

## Saturated Fat (grams)

**Cholesterol (milligrams)**

- = Low-Fat Vegan

- = Pyramid

- = Atkins Maintenance

- 4

- 24

- 38

- 0

- 235

- 834

## Protein (grams)

- Atkins Diet nutrient intakes are based on *Dr. Atkins’ New Diet Revolution* (M. Evans & Co., 1999), using Nutritionist V., Version 2.0, for Windows 98 (First DataBank, Inc., Hearst Corporation, San Bruno, CA).

-                **Low-Fat ****	****   Pyramid             Atkins              Atkins****                Vegan                                     Induction      Maintenance**

## Effects on CholesterolLCHP (“Atkins”) Diets Plus Exercise

***Randomized controlled trials and crossover trials****Bravata DM. JAMA 2003;289:1837-50.**

**Stanford University review, 2003****94 intervention trials**
**≤**** ****60 g CHO/d: No effects on TC, LDL, HDL**
**> 60 g CHO/d: All studies: TC  ****↓****  8.1 ****± 1.4 mg/dl, no other effects****	****	****  Controlled* studies: no effect on lipids**
**Most studies were confounded by exercise.****Most studies did not isolate effects of weight changes on lipids.**

## LCHP Diets and Serum Cholesterol

| Serum Cholesterol

Saturated Fat
Dietary Cholesterol | Serum Cholesterol

Weight Loss |
| --- | --- |

## As Weight Falls, So Does Cholesterol

**Conversion forumla: Cholesterol in mg/dl x 0.02586 = mmol/L****Dattilo AM, Kris-Etherton PM. Am J Clin Nutr 1992;56:320-8.**

**Meta-analysis, Pennsylvania State University**
**1 lb     weight****	****  ****	****TC       1 mg/dl****	****(US units)****	****	****   ****	****LDL    0.4 mg/dl****	**
**1 kg    weight****	****	****TC       0.05 mmol/L****	****(SI units)****	****	****   ****	****LDL    0.02 mmol/L**
**The higher the initial cholesterol level, the greater the cholesterol drop during weight loss.**

## Protein and Loss of Kidney Function 

- Harvard Nurses’ Health Study:
- Among women with mild renal insufficiency (GFR 55 to   < 80 mL/min per 1.73 m2) followed for 11 years:
- Every 10 g non-dairy animal protein → 1.21 mL/min per
- 1.73 m2 drop in GFR
- Atkins Maintenance Diet suggested menu: 135 g protein per day

**GFR = Glomerular filtration rate **
**Knight EL Ann Intern Med 2003;138:460-7. **

## Prevalence of Decreased Kidney Function 

**GFR = Glomerular filtration rate, ****mL/min per 1.73 m****2**
**Coresh J. Am J Kidney Dis 2003;41:1-12. **

|  | Mild (GFR 60-89)  | Moderate (GFR 30-59) |
| --- | --- | --- |
|  |  |  |
| Total population  | 31.2% (0.8)  | 4.3% (0.2)  |
|  |  |  |
| 20-39 years  | 13.7% (0.9) | 0.21% (0.07)  |
| 40-59 years  | 42.4% (1.1)  | 1.8% (0.3)  |
| 60-69 years  | 53.8% (1.8)  | 7.1% (0.9)  |
| 70+    years  | 48.5% (1.1)  | 24.6% (1.1)  |
|  |  |  |

## Prevalence of Decreased Kidney Function 

**GFR = Glomerular filtration rate, ****mL/min per 1.73 m****2**
**Coresh J. Am J Kidney Dis 2003;41:1-12. **

|  | Mild (GFR 60-89)  | Moderate (GFR 30-59) |
| --- | --- | --- |
|  |  |  |
| Total population  | 31.2% (0.8)  | 4.3% (0.2)  |
|  |  |  |
| 20-39 years  | 13.7% (0.9) | 0.21% (0.07)  |
| 40-59 years  | 42.4% (1.1)  | 1.8% (0.3)  |
| 60-69 years  | 53.8% (1.8)  | 7.1% (0.9)  |
| 70+    years  | 48.5% (1.1)  | 24.6% (1.1)  |
|  |  |  |
| With diabetes  | 40.4% (1.9)  | 14.2% (1.3) |
|  |  |  |

## Prevalence of Decreased Kidney Function 

**GFR = Glomerular filtration rate, ****mL/min per 1.73 m****2**
**Coresh J. Am J Kidney Dis 2003;41:1-12. **

|  | Mild (GFR 60-89)  | Moderate (GFR 30-59) |
| --- | --- | --- |
|  |  |  |
| Total population  | 31.2% (0.8)  | 4.3% (0.2)  |
|  |  |  |
| 20-39 years  | 13.7% (0.9) | 0.21% (0.07)  |
| 40-59 years  | 42.4% (1.1)  | 1.8% (0.3)  |
| 60-69 years  | 53.8% (1.8)  | 7.1% (0.9)  |
| 70+    years  | 48.5% (1.1)  | 24.6% (1.1)  |
|  |  |  |
| With diabetes  | 40.4% (1.9)  | 14.2% (1.3) |
|  |  |  |
| Hypertension, no meds  | 43.2% (1.5)  |  7.9% (0.7) |
| Hypertension, on meds  | 46.0% (1.9)  | 17.5% (0.9) |

## Most studies of high-protein diets:

**Bravata DM. JAMA 2003;289:1837-50.**

-  Do not report effects on kidney function
-  Do not track long-term effects

## Calcium LossesVia Kidney (milligrams/day)

- Regular Diet

- Atkins Induction

- Atkins Maintenance

- Reddy ST. Am J Kidney Dis 2002;40:265-74.

## Most studies of high-protein diets do not track:

**Bravata DM. JAMA 2003;289:1837-50.**

-   calcium losses
-  bone density
- long-term fracture risk

## Meat Eating and Colon Cancer

**	****1. Giovannucci E. Cancer Research 1994;54:2390-7. ****	****2. Willett WC. N Engl J Med 1990;323:1664-72.**

- Risk of Colon Cancer from Eating Beef, Pork, or Lamb

**Rarely or Never**

**≥**** ****5/wk, Men****1**

**Daily, Women****2**

**1.0**

**3.6**

**2.5**

## Studies of high-protein diets have been too brief to assess colon cancer risk. 

## Fat and Alzheimer’s Disease

**Chicago Health and Aging Project**
**815 healthy individuals, = 65 years old**
**3.9 year follow-up**

| Saturated fat: | Highest quintile:Lowest quintile: | 25.1 g/day
13.0 g/day | Risk 2.2 (CI, 1.1-4.7) |
| --- | --- | --- | --- |
|  |  |  |  |
|  |  |  |  |

- Rush-Presbyterian/St. Luke’s Medical CenterMorris MC. Arch Neurol 2003;60:194-200.

## Fat and Alzheimer’s Disease

**Chicago Health and Aging Project**
**815 healthy individuals, = 65 years old**
**3.9 year follow-up**

| Saturated fat: | Highest quintile:Lowest quintile: | 25.1 g/day
13.0 g/day | Risk 2.2 (CI, 1.1-4.7) |
| --- | --- | --- | --- |
| Trans fat: | Highest quintile:Lowest quintile:
 | 2.3-4.8 g/day
1.8 g/day | Risk 1.8-2.9* |
| n-6 fats: | Highest quintile:Lowest quintile:
 | 14.5 g/day
7.4 g/day | Risk 0.3 
(CI, 0.1-0.9) |

- Rush-Presbyterian/St. Luke’s Medical CenterMorris MC. Arch Neurol 2003;60:194-200.*Significant for 2nd and 3rd quintiles only

## Three Different Approaches

- Sugar  Fruits  Beans  Grains  Vegetables  Dairy  Eggs  Meat  Fats

-   Sugar  Fruits  Beans  Grains  Vegetables  Dairy

- Dairy  Eggs  Meat  Fats

**Atkins Diet**

**Vegan Diet**

**Low-Calorie Diet**

## Weight Loss: 1 lb/week

**	****1. Barnard ND, in press. ****	****	****	****	****	****	****	****2. Wadden TA. Ann Int Med 1993;119:688-93. ****	****	****	****	****	****3. Westman EC. Am J Med 2002;113:30-6.****	****	****	****	****	**

- = Vegan diet, no exercise (14 weeks)1

- = 1200-calorie diet (21 weeks)2

- = Atkins Diet plus exercise, supplements (26 weeks)3

- Weeks

- Pounds Lost

## Weight Loss per Week (pounds)

- 1. Westman EC. Am J Med 2002;113:30-6; 2. Wadden TA. Ann Int Med 1993;119:688-93; 3. Barnard ND, in press.

-  Vegan                  (14 weeks)1

- 1200-calorie               (21 weeks)2

- Atkins                   + exercise             (26 weeks)3

## Long-Term Weight Loss

**	****1. Westman EC. Am J Med 2002;113:30-6.****	****2. Ornish D. JAMA 1998;280:2001-7.**

- = Vegetarian diet plus exercise2

- = Atkins Diet plus exercise, supplements1

## The Latest Industry Myth

**“****Dairy products promote weight loss.” **
**Evidence based solely on mouse studies or experiments using calorie-restricted diets. **
**Randomized trials adding dairy products to normal diets either have no effect on weight or cause weight gain. **
**Non-fat milk derives 55% of calories from sugar (lactose.) **
**Typical cheeses derive approximately 70% of calories from fat, mostly saturated fat. **

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## The New FourFood Groups

- Grains (rice, bread, pasta, corn, oatmeal, etc.)
- Legumes (beans, peas, lentils)
- Vegetables (carrots, broccoli, spinach, squash, etc.)
- Fruits (apples, bananas, pears, cherries, etc.)

## Physicians Committee for Responsible Medicine

- Neal D. Barnard, M.D.
- 5100 Wisconsin Avenue NW, Suite 400
- Washington, DC 20016
- 202-686-2210
- pcrm@pcrm.org