Dietary Determinants of Obesity

Dietary Determinants of Obesity
Prof. Arne Astrup
Dietary Determinants
of Obesity
Arne Astrup
Director & professor, MD, Ph.D.
RVA University, Copenhagen,
Danmark
Environmental factors causing

weight gain and obesity
Impaired sleep Drugs causing
Soft drinks weight gain
Beer & wine Inactiv ity

(TV, computers)
Dietary fat, Lack of habitual

CHO Meal
size/ physical activ ity
& protein
bioactiv e energy
intake Sports
ingredients
activ ities
Breast
feeding Smoking
cessation
High birth
weight Organo
chlorines
3
The screen versions of these slides have full details of copyright and acknowledgements 1
Prof. Arne Astrup
Genes are assumed

to interact with dietary fat
low high
Spectrum of genetic Weight Spectrum of environment

predisposition change
Dietary fat
high low
Diet, sedentarity, depression, stress, smoking…..
Portion size
Prof. Arne Astrup
Soft drink single serving size,

1950 - 2002
8 ounces 12 ounces 20 ounces 42 ounces

5¢ per oz. 4¢ per oz. 2.3¢ per oz. 7
Proportion of total calories obtained

away from home, 1977 - 1995
40
Percent of total calories
30
Away from home
20
Fast food
Restaurant
10
School
0
1979
1983
1985
1987
1989
1991
1995
1977
1981
1993
Source: USDA/ERS, 1999

8
Recommended nutrient content

of a weight-reducing diet
Protein 8%-10%Saturated fatty

acids
15%
Fat
Carbohydrate <10%Polyunsaturated
>55% <30% fatty acids
<15%Monounsatur ated
fatty acids
Calories: 500-1000 kcal/d reduction

Cholesterol: <300 mg/d
Fiber: 20-30 g/d
Clinical guidelines on the identification, evaluation and treatment of overweight
and obesity in adults– the evidence report. Obes Res. 1998;6 (suppl 2) 9
Prof. Arne Astrup
High-fat diets increase the risk

of obesity and type 2 diabetes –
health professionals study
Relative risk
Crude
of diabetes
2 BMI adj
1,8
1,6
1,4
1,2
1
0,8
0,6
0,4
1 (24 % ) 2 (29% ) 3 (32% ) 4 (35% ) 5 (39% )
Quintiles of fat intakes (%)
Van Dam, Willett, Rimm et al., Diabetes Care 2002 10
Cumulative food and energy intakes:

role of energy density
Weight of food Energy consumed
consumed (g) (kcal)
Low Low
3000
Medium 4000 Medium b
High 3600 High c

2500
a
3200
b
2000 2800 b
a
2400 a
b a
1500 2000 b a
b a a
1600
a a
1000
1200 a
ba a
800
500
a
400
0 0
B L D S B L D S B L D S B L D S
Day 1 Day 2 Day 1 Day 2
Meals Meals
Different letters are significantly different at p < 0.05
Bell et al., Am J Clin Nutr 67: 412-20, 1998 11
Fast food
With permission from McDonald’s Corporation 12
Prof. Arne Astrup
Prentice & Jebb, Obesity Reviews, Nov 2003 13
Evidence based guidelines
14
Meta-analysis of low-fat diets I
”A reduction of 10 % in the proportion

of energy from fat was associated
with a reduction in weight of 16 g/d”
~1.4 - 2.8 kg over 3 - 6 mo
Bray & Popkin. AJCN 1998; 68: 1157-73
15
Prof. Arne Astrup
Meta-analysis of low-fat diets

effect on body weight
Lee-Han et al. (1988)
Boyd et al. (1990)
Buzzard et al. (1990)
Bloemberg et al. (1991)
Sheppard et al. (1991)
Baer (1993)
Hunninghake et al. (1993)
Kasim et al. (1993)
Raben et al. (1995)
Pritchard et al. (1996)
Siggaard et al. (1996)
Simon et al. (1997)
Weststrate et al. (1998)
Stefanick et al. F (1998)
Stefanick et al. M (1998)
Skov et al. HP (1999)
Skov et al. LP (1999)
Saris et al. SCHO (2001)
Saris et al. CCHO (2001)
Weighted overall (fixed effects)

Weighted overall (random effects)
-10 0 10 20
Weight loss difference (I - C) kg
Astrup et al., Int J Obes 2000; 83:25-32 16
Meta-analysis of low-fat diets

effect on body weight
The low fat intervention groups showed
a greater reduction in energy intake
(1138 kJ/d, P = 0.002) –
and a greater weight loss than control groups
(3.2 kg, 95% CI: 1.9-4.5, P < 0.0001)
A 10 kg higher initial body weight was associated

with a 2.6 kg (P < 0.01) greater difference in weight loss
(3.2 + 2.6 = 5.8 kg)
Astrup et al., Int J Obes 2000; 83:25-32 17
A typical long-term randomized ad lib

low-fat diet study
kg
Changes in weight
Low adherence
High adherence
Years
A reduction in dietary fat from 35 to 25 % of total energy
produced a mean weight loss of 3.3 kg after one year
Swinburn et al., Diabetes Care 2001; 24: 619-24

18
Prof. Arne Astrup
Meta-analysis of low-fat diets III
Yu-Poth et al., AJCN 69:1999 19
Women’s health initiative

dietary modification trial
Control
Intervention
Mean difference (kg)
Years of intervention
Howard et al., JAMA 2006;295,39-49 20
Women’s health initiative

dietary modification trial
Howard et al.,
al ., JAMA 2006;
2006;295
295,39
,39--49 21
Prof. Arne Astrup
22
Diabetes prevention program:

National Institute of Diabetes and Digestive
and Kidney Diseases (NIDDK)
Goals for lifestyle treatment:
• ≥ 7 % weight loss (maintained)
• 1200 – 1800 kcal/day
• ≤ 25 E % from fat
• ≥ 150 min brisk walking/week
16 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 yr
and 5% for study duration
23
Successful weight loss

with a hypo caloric-low fat diet
and increased physical activity (n = 3234)
Prof. Arne Astrup
Reductions in the incidence of diabetes

with a hypo caloric-low fat diet
and increased physical activity
40
Placebo
RR*
Metformin
31%
Cumulativ e incidence
30 Lifestyle RR*
of diabetes (% )
58%
20
10
0
0 1.0 2.0 3.0 4.0
Year of treatment
*Reduction in risk of progressing to type 2 diabetes versus placebo
Walter Willett´s ”new healthy diet pyramid”
26
Where are the differences ?
Source: Dept. of Agriculture/U.S. Dept. of Health and Human Services

By Adrienne Lewis, USA TODAY 27
Prof. Arne Astrup
Dietary composition of ad libitum diets:

Willett vs. USDA
High fat, Low fat diet
Diet component
MUFA rich diet (NNA)
Energy intake Ad libitum Ad libitum

Total fat 40 % 25 %
Carbohydrate + fiber 45 % 60 %
Protein 15 % 15 %
Energy density High Low
Added sugars <10% <10%
Glycemic index Low index Medium index
Monounsaturated fatty >20 % <10 %

acids
Saturated fatty acids <10% <10%
Polyunsaturated fatty >5% >5%
acids
Alcohol <5% <5%
28
Major changes from USDA/NNR
More whole grain products
Less potatoes, rice and pasta
More nuts, almonds etc.
More plant oils
Less dairy products
Less red meat
29
We eat too little whole grain rye bread
Intake of rye bread

have decreased
from 100 g/d in 1955
to 50 g/d in 1990
30
Prof. Arne Astrup
Consumption of soft drinks, potatoes,

and prevalence of overweight among children
in Denmark 1947-2003
Usage of soft drinks L/person/year
Overweight for children (%)
Usage of potatoes 10g/person/year
Overweight (%)
Soft drinks incl.

water and ice tea
Soft drinks L/person/year
Potatoes
10g/person/year
Prevalence
Potatoes of overweight
for children from
6-16 year (%)
31
Which choice of 1,760 kJ

offers most satiety?
French fries 164 g Baked potatoes (3 pieces)
(10.6 kJ/g) 500 g (3.6 kJ/g)
32
How much food for 1,625 kJ?

does energy density matter?
Potatoes 450 g
(3.6 kJ/g)
Avocado 260 g
(7.7 kJ/g)
33
Prof. Arne Astrup
Which choice of 420 kJ

Strawberries 250 g (1.8 kJ/g)
Olives 50 g
(8.4 kJ/g)
34
Which choice of 1,330 kJ

Carrots 850 g (1.8 kJ/g)
Roasted peanuts
50 g (26.4 kJ/g)
35
Almonds as a slimming tool?

Weigh (kg)
Week
Wien et al., IJO 2004 36
Prof. Arne Astrup
Recommended nutrient content

of a weight-reducing diet
Protein 8%-10% Saturated

fatty acids
15%
Fat
Carbohydrate <10% Polyunsaturated
>55% <30% fatty acids
<15% Monounsatur ated

fatty acids
Calories: 500-1000 kcal/d reduction

Cholesterol: <300 mg/d
Fiber: 20-30 g/d
Clinical guidelines on the identification, evaluation and treatment of overweight

and obesity in adults– the evidence report. Obes Res. 1998;6 (suppl 2) 37
38
Background
A diet rich in foods with a low glycemic index (GI) –
such as pasta, beans, lentils and certain fruits –
has been claimed beneficial in relation to appetite
and body weight control;
However, the experimental evidence
is not yet there
(Raben, Obes Rev 2002;3:245-56) 39
Prof. Arne Astrup
The glycemic index (GI)

Glycemic index (GI) = iAUC test food / iAUC reference food
– In vivo standard method in 1998 in FAO/WHO report
– In vitro methods
Glycemic load (GL) = Σ g CHOfood item*GIfood item / 100
Mean GI of diet or meal:
– GImeal/diet = GL * 100 / total g CHO meal/diet
– 1998: FAO/WHO report include equation
for calculating GI in mixed meals
Predicted GI vs. measured GI

• The objective of the present study was to investigate
the predictability of measur ed GI in composi te breakfast meals
when calculated from table values,
and to devel op prediction equations
using meal components;
Furthermore, we aimed to study the relationshi p
between GI and insulinaemi c index (II)
• The study was a randomiz ed cross-over meal test
including twenty- eight healthy young men;
Thirteen breakfast meals and a reference meal
were tested; All meals contained
50 g availabl e carbohydr ate,
but differed consider abl y in energy and macronutri ent compositi on
Flint, Raben, Astrup et al., Br J Nutr 2004;91:979-89 41
Results – body weight

0,00 pdiet= 0.4401
-0,50 ptime= 0.0001
W eight change, kg
-1,00
HGI group,
-1,50 n = 22
LGI group,
-2,00 n = 23
-2,50
-3,00
0 2 4 6 8 10 12
W eeks
Sloth et al., Am.J.Clin. Nutr. 2004;80:337-47
Prof. Arne Astrup
CARMEN
CARMEN
Change in body weight

3
2
² weight (kg)
-1
p < 0.05
-2
p < 0.001
-3
SCHO CCHO CD CS
group
Saris, Astrup, Prentice et al., Int J Obes 2000;24:1310-8
• Consumption of sugar-sweetened drinks

is associated with weight gain
and development of type II diabetes
and obesity in children
• Sugar calories in drinks do not produce
the same satiating effect as sugar in solid foods
Lancet 2001; 357; 505-08 44
The importance
of the non-fat component
Raben et al., Am J Clin Nutr 2002; 76: 721-9 45
Prof. Arne Astrup
The importance
of the non-fat component
Sugar-rich beverages increase body weight
W eight changes
2,5 Sucrose
Sweetener
1,5
0,5
-0,5
Group x time, p < 0.001
-1,5
-2,5
0 2 4 6 8 10
W eeks
Raben et al., Am. J. Clin. Nutr. 2002, 76: 721-9 46
Popular high-protein
diet books
Low carbohydrate vs. low fat

(completers analysis)
0
Low fat
Weight Loss (%)
-5
Low carb
-10
-15
0 3 6 9 12
Months of Diet
Foster et al ., NEJM 2003;
Prof. Arne Astrup
Low-carb
and physical performance
• The physical performance is deteriorated

by a low carb diet
Achten J. et al., Higher dietary carbohydrate content during intensified running

training results in better maintenance of performance and mood state;
J Appl Physiol. 2004 Apr, 96 (4):1331-40 49
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
50
51
Prof. Arne Astrup
The south beach diet

Composition of the study diet
Phase 2 Phase 2 Phase 3
Component
(W eeks 1-2) (W eeks 3-4) (W eeks 6-12)
Protein 29 30 39
Carbonhydr ated 10 27 28
Fat
Saturated 19 8 8
Monounsatur ated 17 62 18 49 17 39
Polyunsaturated 32 17 14
Total 100 100 100
Values are given as daily percentage of caloric intake

Aude YW et al.; Arch.Int Med.2004, 164, 2141-6
Proposed hierarchy of satiety

Need hypothesis-dri ven studies to determine differences
Leucine
Protein
Fructose
Carbohydrate
Fiber
mct
Sucrose
Fat
53
Effect on satiety –
how satisfied do you feel?
10 I cannot eat another bite
9
Visual analogue scale (cm)
8
7
6
5
4
3 High-Protein meals
2 Normal protein meals
1
I am completely empty
0
8 10 12 14 16 18 20 22 24
Time
54
Prof. Arne Astrup
Results 24 hour
energy expenditure
PORK: 13.11 ± 1.00 MJ/d a (3.9%)
SOY: 12.86 ± 0.98 MJ/d b (1.9%)
CARBO: 12.62 ± 0.98 MJ/d c
BASELINE: 12.52 ± 1.06 MJ/d b,c
Pork versus Soy: 1.9% (P < 0.05)
Mikkelsen et al., Am J Clin Nutr 2000;72:1135-41 55
Methods
• Subjects: 50 overweight and obese (25 in control group)
– Men (n = 12) and women (n = 38)
– Age: 19-55 years
– BMI: 26-34 kg/m2
– Free from illness (CVD, T2D etc.)
• One-year randomised dietary intervention,
comparing an ad libitumfat-reduced diet
(30% of energy) either
– High in protein (25% of energy, HP) or
– Medium in protein (12% of energy, MP)
– Normal fat control group (only 6 months)
56
57
Prof. Arne Astrup
RDI: at least 130 g carbohydrate/day
Atkins: 20-50 g/d
Adverse effects: muscle cramps, headache, weakness,

diarrhea etc.
Astrup, Larsen, Harper. The Lancet. 2004; 364: 897-9
The importance
of the non-fat component ?
or
Protein versus carbohydrate

Macronutrient composition of diets
(% of total energy)
25% 12% 19%

58%
PROT
36%
45% CHO
FAT
45%
30% 30%
HP HC C
60
Prof. Arne Astrup
Plots of changes in percentage of energy

as macronutrients in the diets of 13 countries
with developed market economies
over the period 1970–2000,
against the incidence of adult obesity
during the early mid-1990s;
Dietary data are from the FAOSTAT database (13),
and represent nutrient supply rather than consumption;
1, Australia; 2, Canada; 3, Denmark; 4, Finland;
5, France; 6, Germany; 7, Italy; 8, Netherlands;
9, New Zealand; 10, Spain; 11, Sweden; 12, UK; 13, USA
61
A randomized 6-months trial

on two fat-reduced diets (28% energy):
high CHO vs. high protein
24-h urinary nitrogen excretion
24-h UN (g)
High adherence
can be achiev ed
by prov iding all foods
free of charge
Duration of dietary intervention (months)
Skov AR et al. Int J Obes 1999; 23: 528-36 62
A randomised 6-months trial

on two fat-reduced diets (28% energy):
high CHO vs. high protein
Weight
Body loss
composition and fat loss
Body weight (kg)
Mean value after

6 months dietary
intervention
T ime (weeks)
Skov AR et al., Int J Obes 2002; 23: 528-36 63
Prof. Arne Astrup
Protein reduces
intra-abdominal fat
6 12
0
-5
-10 Medium-protein
-15 High-protein
-20
-25 P=0.03
-30
-35
P=0.002
-40
64
Background
Several studies have identified an inverse association
between body fatness and calcium intake
Calcium from low-fat dairy products
seem to have a more pronounced effect

than calcium supplementation
The mechanisms are unknown
65
Calcium intake vs. fat excretion

Fat excretion (g/day)
25
20
y = 0,0054x + 4,1285
15
10
5
0
0 500 1000 1500 2000 2500
Calcium intake (mg/day)
Hansen JK, Jacobsen R, Astrup A. Int. J.Obes (In press)
Prof. Arne Astrup
Excretion of fat (% of intake)
30
Fat excretion (% ingested fat)
p < 0.001
25
20
15
10
0
Low Calcium
Low calcium Highcalcium
High Calcium
Hansen JK, Jacobsen R, Astrup A. Int. J.Obes (In press)
US recommendations
AMDR (DRI, Institute of Medicine, USA)
Protein:
Adults: 10-35%
Older children: 10-30%
Smaller children: 10-20 %
68
Institute of Medicine, USA

For young and older children,
the RDA is approximately 5-10 E%, respectively
To complement the AMDR for fat (30-40E%),

and carbohydrate (45-65E%) for young children
and older children (25-35 E% for fat,
and 45-65 E% for CHO), protein intakes may range
from 5-20% for young children,
and 10-30% for younger children
69
Prof. Arne Astrup
RTD line 1:
dietary intervention budget:
3.7 mio. € (27 mio.kr)
Dietary intervention in whole families
– Ad libitumdiet most effective against weight (re)gain
– Long-term (6/12 months) large-scale intervention
study (700 adults randomized plus
350-1050 children – 1-3 children/family)
Factorial design (5 groups): Low GI High GI
– High/low glycaemic index Normal

1 2
protein
– High/normal protein High
protein 3 4
– Control Control 5
70
71

Dietary Determinants of Obesity

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Dietary Determinants of Obesity

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Dietary Determinants of Obesity

Prof. Arne Astrup

Environmental factors causing

Beer & wine Inactiv ity

Dietary fat, Lack of habitual

Genes are assumed

Spectrum of genetic Weight Spectrum of environment

Diet, sedentarity, depression, stress, smoking…..

Soft drink single serving size,

8 ounces 12 ounces 20 ounces 42 ounces

Proportion of total calories obtained

Source: USDA/ERS, 1999

Recommended nutrient content

Protein 8%-10%Saturated fatty

Calories: 500-1000 kcal/d reduction

High-fat diets increase the risk

Van Dam, Willett, Rimm et al., Diabetes Care 2002 10

Cumulative food and energy intakes:

High 3600 High c

With permission from McDonald’s Corporation 12

Prentice & Jebb, Obesity Reviews, Nov 2003 13

Evidence based guidelines

Meta-analysis of low-fat diets I

”A reduction of 10 % in the proportion

Bray & Popkin. AJCN 1998; 68: 1157-73

Meta-analysis of low-fat diets

Weighted overall (fixed effects)

Astrup et al., Int J Obes 2000; 83:25-32 16

Meta-analysis of low-fat diets

A 10 kg higher initial body weight was associated

Astrup et al., Int J Obes 2000; 83:25-32 17

A typical long-term randomized ad lib

Swinburn et al., Diabetes Care 2001; 24: 619-24

Meta-analysis of low-fat diets III

Yu-Poth et al., AJCN 69:1999 19

Women’s health initiative

Women’s health initiative

Diabetes prevention program:

Age 51 yr; BMI 34 kg/m2; average follow-up 2.8 yr;

Successful weight loss

Reductions in the incidence of diabetes

Walter Willett´s ”new healthy diet pyramid”

Where are the differences ?

Source: Dept. of Agriculture/U.S. Dept. of Health and Human Services

Dietary composition of ad libitum diets:

Energy intake Ad libitum Ad libitum

Monounsaturated fatty >20 % <10 %

Major changes from USDA/NNR

More whole grain products

Less potatoes, rice and pasta

More nuts, almonds etc.

More plant oils

Less dairy products

Less red meat

We eat too little whole grain rye bread

Intake of rye bread

Consumption of soft drinks, potatoes,

Soft drinks incl.

Which choice of 1,760 kJ

How much food for 1,625 kJ?

Which choice of 420 kJ

Strawberries 250 g (1.8 kJ/g)

Which choice of 1,330 kJ