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EDITORIAL |
1 From the Department of Human Nutrition, Centre for Advanced Food Studies, Royal Veterinary & Agricultural University, Copenhagen, Denmark
2 Reprints not available. Address correspondence to A Astrup, Department of Human Nutrition, Royal Veterinary & Agricultural University, Rolighedsvej 30, DK-1958 Frederiksberg C, Denmark. E-mail: ast{at}kvl.dk.
See corresponding article on page 41.
There is an urgent need for effective tools to prevent weight gain in the population at large and weight regain in overweight persons after weight loss. In theory the solution is simple, but implementation will continue to be difficult and ineffective as long as we maintain the view that just telling people that they should eat less and exercise more does the job. This simplistic strategy assumes that humans have conscious control over appetite and body weight regulation, which is certainly not the case for most people; if it were true, there would be no overweight or obese people. I have never met an obese patient who has worked hard to become obese and to maintain an excessive body size. We need to acknowledge that our regulatory systems are geared to prevent depletion of body energy stores and undernutrition effectively, whereas the systems that reduce appetite and increase energy expenditure during periods of excess availability of foods are easily suppressed by palatability and by the social, psychological, and rewarding aspects of foods.
In the past, when people expended plenty of calories just by going about their daily business, it was possible to remain slim while eating a diet with nearly any nutritional profile. The problem nowadays is that many people are extremely sedentary, which makes it possible to overeat even when dietary intakes are relatively small. For example, it is easy to prepare tasty, filling meals with drinks for an active person who needs 
2500 kcal/d, but it is difficult to do the same for a sedentary person who needs only 1800 kcal/d. This is why the current focus of science is to increase the satiating power of the diet, so that people feel full with fewer calories.
An ad libitum diet that reduces the fat content from 40% to 25–30% of energy produces some weight loss (1). It is highly probable that the obesity rate would have increased even more over the past 20 y if the dietary fat content had not decreased during this period. However, because of the concomitant reductions in energy needs, increases in portion sizes, and increases in soft drink consumption that have occurred during the same period, the slight reduction in dietary fat over this time has clearly been insufficient to prevent weight gain and the increasing prevalence of obesity. The high obesity rate has also created a market for alternative, and often unsubstantiated, dietary solutions.
The higher than usually recommended protein content of many popular diets, such as the Atkins Diet, The Zone, and The South Beach Diet, seems to point at possible solutions to the obesity epidemic. Many national dietary guidelines have, until recently, recommended that only 10–20% of the calorie content of the diet come from protein; however, 30–40% of the calorie content in the aforementioned diets comes from protein, at the expense of carbohydrates. Newer research indicates that the high-protein content of these diets may actually be the reason for their partial success in inducing weight loss, despite no restrictions in total calories (2). High-protein diets, such as the Atkins diet, may also suppress food intake by producing ketosis. Ketosis results from the depletion of glycogen stores induced by a severe restriction of carbohydrates, to an extent that goes far beyond what is commensurate with a healthy diet.
In this issue of the Journal, Weigle et al (3) showed that an increase in dietary protein from 15% to 30% of energy and a reduction in fat from 35% to 20%, at a constant carbohydrate intake, produces a sustained decrease in ad libitum calorie intake and results in significant weight loss. They sequentially assigned 19 persons to the following diet regimens: 2 wk of a weight-maintenance diet (15% of energy as protein, 35% as fat, and 50% as carbohydrate), 2 wk of an isocaloric diet (30% of energy as protein, 20% as fat, and 50% as carbohydrate), or 12 wk of an ad libitum diet (30% of energy as protein, 20% as fat, and 50% as carbohydrate). They found that the subjects felt more satiated with the isocaloric high-protein diet than with the weight-maintenance diet. When the subjects were given the possibility to regulate their energy intake under the ad libitum conditions, spontaneous calorie intake decreased by 441 kcal/d, body weight decreased by 4.9 kg, and fat mass decreased by 3.7 kg. We do not yet understand how protein increases satiety. Weigle et al found that the effect could not be explained by changes in the hunger hormone ghrelin or in the satiety hormone leptin.
Weigle et al's results clearly showed that protein is more satiating than is fat, and previous studies have shown that protein is more satiating than is carbohydrate (4). Moreover, diets with a fat content fixed at 30% of calories produce more weight loss when high in protein (25% of energy) than when normal in protein (12% of energy): 9.4 compared with 5.9 kg after 6 mo; after 1 y, evidence was found to suggest that the high-protein diet, independent of the loss of total body fat, resulted in a significant loss of visceral fat (5).
Should we advise overweight and obese patients to increase their protein intakes from 10–20% to 20–30% of calories and reduce their intake of fat and carbohydrates correspondingly? If fat intake is fixed at 30% of calories, there is still plenty of room for carbohydrates to make up 40–50% of the calories. It is preferable to replace sugars from soft drinks with protein from low-fat milk, high-fat meat and dairy products with the lean versions, and possibly white bread and pasta with lean meat, without reducing the intakes of fruit, vegetables, and whole-grain products. Should we advise the public to increase their intakes of meat and dairy products? The answer depends on the potential adverse effects of a high-protein diet.
The guidelines from the Institute of Medicine allow for the inclusion of higher amounts of protein than previously recommended in a healthy diet (6). This institute concluded that there is no clear evidence that a high protein intake increases the risk of renal stones, osteoporosis, cancer, or cardiovascular disease. Thus, the acceptable protein distribution was set to 5–20% of calories for children aged 1–3 y, 10–30% for children aged 4–18 y, and 10–35% for adults. There is clearly a need for more long-term dietary intervention trials to address these issues, and the European Union has just funded (18 million dollars) the DiOGenes (Diet, Obesity, and Genes) project, the core of which is a large multicenter trial of high- compared with low-protein diets and of high- compared with low-glycemic-index diets in obese and overweight families (7). This trial, which may involve participation by the United States, will investigate over 1 y the health effects of high-protein diets in 1500–2000 subjects. Perhaps now is the time to consider the economic and environmental consequences of increasing the population's intake of protein from fish, meat, and vegetables and how this increase can be incorporated into the local cuisine.
ACKNOWLEDGMENTS
AA is a member of several advisory boards for the food industry, is a Medical Advisor for Weight Watchers, and heads the dietary intervention study in the DIOGENES project (coordinated by WHM Saris, Netherlands); his department receives grants and food donations from 150 food companies.
REFERENCES
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 D. Paddon-Jones, E. Westman, R. D Mattes, R. R Wolfe, A. Astrup, and M. Westerterp-Plantenga Protein, weight management, and satiety Am. J. Clinical Nutrition, May 1, 2008; 87(5): 1558S - 1561S. [Abstract] [Full Text] [PDF]
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A. L. Gunther, T. Remer, A. Kroke, and A. E Buyken Early protein intake and later obesity risk: which protein sources at which time points throughout infancy and childhood are important for body mass index and body fat percentage at 7 y of age? Am. J. Clinical Nutrition, December 1, 2007; 86(6): 1765 - 1772. [Abstract] [Full Text] [PDF]
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B. L. Luhovyy, T. Akhavan, and G. H. Anderson Whey Proteins in the Regulation of Food Intake and Satiety J. Am. Coll. Nutr., December 1, 2007; 26(6): 704S - 712S. [Abstract] [Full Text] [PDF]
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A. E Buyken, K. Trauner, A. L. Gunther, A. Kroke, and T. Remer Breakfast glycemic index affects subsequent daily energy intake in free-living healthy children Am. J. Clinical Nutrition, October 1, 2007; 86(4): 980 - 987. [Abstract] [Full Text] [PDF]
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F. Contaldo and F. Pasanisi High-protein diet, obesity, and the environment Am. J. Clinical Nutrition, February 1, 2006; 83(2): 387 - 387. [Full Text] [PDF]
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H. S Callahan, C. C Matthys, J. Q Purnell, and D. S Weigle Reply to F Contaldo and F Pasanisi Am. J. Clinical Nutrition, February 1, 2006; 83(2): 388 - 388. [Full Text] [PDF]
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