THE

AMERICAN

JOURNAL

OF

Clinical
VOLUME

Nutrition
23 #{149}NUMBER 9

SEPTEMBER

1970

Guest

Editorial

The

Myth

of Diet o
GEORGE

in the esity
#{149} 123

Management

A.

BRAY

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O
proaches

BESITY

IS

WIDESPREAD

MALADY

in

our nonathietic

individual, to
of

overweight excess
obesity

is almost The
best

society, yet eludes medical

therefore, empirical. have

its underlying science and

Many been tried

its
including

cause therapy
ap-

stillassuredly due and is, significance

veyed from

fat.
can

prevalence be conindi-

therapeutic

the

diets

of

United cates that

States

following statistics. The Public Health Service of the adult

all health tion

kinds, of

total

and

intermittent

starvation,

25-45%

American

spas, exercise machines, various types. Recent

provides appointing
using a

and medica- population over 30 years of age is more than information 20% overweight (1). In childhood, obesity, defined as 40% or more above the median some insight into the generally disfor height, occurred with an inciresults that have been obtained weight
approach. dence of

dietary

2-15%
among Manhattan more

(1). all

This segments
has common shown

burden

is

not

Obesity
greater weight. than

exists
normal Overweight,

when
fraction on

fat the tables

other

makes total of
hand,

up body
is

borne a

equally

A sity

study is

in

of society. that obethe in lowest with importance increased with Study

obese angina pectoris

7 times

defined

in

relation

to

of

ideal

weight socioeconomic
is

group (2).
clear morbidity

as The

compared

the

that have usually been prepared by life inhighest group surance companies. It is fair to say that of corpulence obese people are usually overweight, but mortality and that not all overweight people are obese.overweight. In Since it is easy to measure weight, but more factors related difficult epidemiological is a from
abnormality

medical from the

associated

the
to

Framingham
heart prone disease, to

of
sub-

to hazard studies

quantitate data to
in

fatness, implying in the than

Medical Medicine, Boston, Institutes given 1, 1970. to the

most that

of obesity

the jects and

were

more

to

sudden

death In

than

were addition,

people diabetes

of

health are of overweight.

weight exceeds

height
From pitals versity Grants Based Dairy and

and
the School AM on Council,

age
New Department of by 09897 a April

by

more

fact derived normal weight (3). When the mellitus, gall bladder ideal for tory disease are all 30% in the overweight patient.
Center Tufts UniHealth England HosRATIONALE FOR DIETARY

disease, and more common

respirain the

England of National and lR-52.

MANAGEMENT

Medicine,

Massachusetts. of New

OF

OBESITY

Supported

In cause
greater

the the than

simplest caloric the

terms, value daily of

obesity ingested requirements.

occurs food Excess

beis

lecture

1141

1142 calories fatty cells most late intake acids not used and are each day stored are in be fat converted adipose

Bray our obese patients to kcal/m2 (7). This tissue square kcal, on body
oxygen

had means of average, weight.

consumption

the that surface

slope for area

of each an

1,100 addiextra to

because this site can without limit. Excess in persons continuing if energy expenditure by

tional expanded alcan accumu- 1,100 maintain normal food

meter the

is required just This relationship and surface the same is essentially

is reduced. in obese Bullen

dence for this mechanism girls has been presented leagues

document

between Eviin teenage area

obese

patients lean lean

and

(4),
that

who utilized obese girls

motion were thin (5),

pictures measurably

one for col- as the that obese and to calorie requirement From that, of to

individuals, indicating people have the same per unit surface area. an we can individual calculate with a

less active than their Chirico and Stunkard

contemporaries. using pairs

this information gain weight,

area of 2 m2 would require in excess obese and lean subjects of the same sex andsurface of 2,200 kcal daily. As most of our obese paoccupation, showed that activity was less in tients were between 2 and 3 m2 (correspondthe obese member of most pairs. The most to 250-450 lb.), a diet containing 3,500 striking exalnpie of obesity due to reduced ing kcal should produce only a slight weight energy output, however, was the report by in individuals in this group. When we Wilkins and his co-workers from the Johns gain Hopkins Hospital (6). They reported year-old child who became almost pletely paralyzed and gained weight whenever daily intake exceeded 500 kcal. A second way in which an imbalance tween calorie intake and expenditure occur is by increasing food consumption while learn maintaining whether normal calorie intake activity. was six obese a placed 6kcal for 1 week, comcrease
clusion

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patients there was thus

on no

a diet significant

of our

3,500 incon-

in
that

weight,
obese

supporting

number of beeven more can would expect that were adequate, To take This fact has excessive sue.

patients require a large calories to maintain weight and to gain weight. Conversely, we if restriction weight been of calorie loss would inenmany

demonstrated

or energy expenditure diminished, titated the energy expenditure grossly obese adult patients ments of oxygen consumption and pies used to of expired calculate air times analyzed carbon been were

(8). we quan- times of a group of RESULTS OF CALORIE (7). MeasureMANAGEMENT were made employing Sam- Clinics each the treatment achieved of poor Laren-Hume of of ex- a number tech-treated obesity, of

RESTRICTION OF OBESITY

IN

THE

energy needs. collected on a period content Energy by this patients. greater oxygen among with

dietary obesity

management in have generally and Mcexperience that have data number at the or have of botof pa40 lb. There

patient several 6-12 days and oxygen and penditure has

a day for for their dioxide. measured

results. Stunkard (10) reviewed the of nutrition clinics and some of these in Fig. 1. The study is shown

nique in more than 30 obese general, heavier patients have quirements for oxygen. Total sumption (energy expenditure) tients had a high correlation and body fat, surface area, a much less significant measures of lean body body water, exchangeable creatinine gen excretion. with consumption

been In summarized patients in each recontom patients total is of

the figure and the percentage achieving a weight loss of 20 by the height of the bars.

shown

body weight correlation mass, such as potassium, data relating area in

The

but was some variability from one study to with another, but in general the percentage lostotaling 20 lb. or more was less than 30% (mean and= 24%). When one looks at the percentage achieving a 40-lb. weight loss the outlook is oxy18 considerably of less satisfactory. Here the aver-

surface

Diet

and

Obesity vidual approached were than 40 diet lb.

for

1143 normal to lb. achieve but only weight, a weight 6% lost another loss more of

0WE1GI4I

LOSS

MORE

IRAN

20

POUNDS

WESHT

LOSS

MOPE

IRAN

40

POuNDS

12% more than new

able 20

50 40 4.2 30

Unfortunately,

produces

the obese its temporary

patient each weight loss, a relapse, or higher this as

H1L{EL1LrkI
314 294 290 46

so

131

100

NUMBER

OF

PATIENTS

but this is with weight levels. Mayer

diet. below

usually returning (9) has method effective

followed by to the same aptly described of diet, girth there

FIG. Number each

1.

Weight
of of indicated for bars

loss

in in and the

patients each percentage

treated study

with listedis
losing

patients

the there
or

was

rhythm an

control. If would be no of new Drinking diet, the Loss diet,

pair

20
left

40
right

lb.

is

by
columns 12, 13,

the 1-7, 14,

height
reading 16, 15,

of

the

bars. from

The
to

need diets: Mans Mayo

for the continuous the Grapefruit diet, diet, the Air the Quick

introduction diet, the Force Weight

references are 11,

10.

Downloaded from www.ajcn.org by guest on February 24, 2012

and so on. It seems obvious from the numof presentber of diets that have been made available limitations. and are continuing to appear, none of them There are always patiems for whom a provides the answer to obesity. weight loss of 20 or 40 lb. would bring them very close to their desired weight and other ADIPOSE CELLS IN OBESITY patients for whoin such weight losses would Two areas of investigation have provided be trivial. To make some correction for a partial explanation for the failures of these factors, Young et al. (16) evaluated calorie restriction in the treatment of obeweight loss in relation to the amount of exsity. Accretion of fat can occur by either encess weight. Thus, patients were divided larging the existing fat cells to accommodate into six groups and the successes evaluated the extra fat, increasing the total number of in relation to the weight to be lost. With infat cells, or by a combination of both (18). creasing initial weight, the success rate fell, We have measured the size of subcutaneous yet it is the heavier patient for whom weight fat cells under a microscope after dispersing loss is more important (Table i). the cells by incubating them in collagenase These observations indicate that dietary (19). The size of subcutaneous fat cells in a treatment of obesity is more likely to succeed in patients who are only modestly overage ing was data only on 9%. Such a method weight loss has its weight. ship of provide weight. as the Clubs eral Diet added weight tients outlook methods. tients Glennon For these similarly It patients afflicted the companionindividuals may incentive that such to lose groups
Initial weight range, lb.

TABLE Weight reduction in

relation

to

initial

an additional is this technique

weight5
Criteria of success (pounds to be lost) Number Total of successes

TOPS (Take have used with

Off Pounds Sensibly) reported success. SevDiet Watchers, means. however, Kitchen, have to In pathe

number

% 44 31 28 14 7 18 26 et al. (16).

other groups, including Workshop, and Weight an additional monetary dietary obesity, reduction by with marked

Under

150

10 15 20 25 30

11/25 11/36 13/47 3/22 1/15 2/11 41 /156

incentive

151-175 176-200 201-225 226-250 Over Total Modified from 250

would appear bleak for In a follow-up study who were 50% or more (17) found that only

any of these of 199 paoverweight, one mdi-

35

the

data

of Young

1144
group of obese and control patients

Bray
is shown

in

Fig.

2.

Subcutaneous

fat

cells

from

the lapaof the the had this obese subcu200

0)

#{149}=

FEMALES MALES

control rotomy) fat one lost cells

subjects (patients were about one-third from the obese fat patient with 120 lb. prior to we have the his

undergoing the size Indeed, cells From that larger smallest biopsy.

#{149} .

subjects.

x
If) -J -J

comparison patients

would conclude considerably

Ui 0

#{149} . .
I II

UU0

taneous fat cells than the control group there lation (P < 0.05) between cells clude cells companied taneous fat We have fat cells by and that and that in body weight. the part heavier by

control subjects. In was a positive correthe volume of fat Thus, we had of would larger fat of subcuconfat is ac-

00
a-

a:
Ui

#{149} #{149}
#{149}

.
I

z
-J

patients accumulation enlargement

I-

0
I-

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CONTROL

OBESE

control andobese of patients. paof greater than +0.90 (P < 0.01). We tients we measured the total body watercient have assumed that subcutaneous fat cells from the distribution of tritiated water and used these data to calculate the total are representative of all fat cells.4 It would appear that many grossly obese individuals amount of fat (7). In the control patients it an increased number of fat cells as well was not possible to measure their total body have fat cells (Fig. 3). The increased water by isotopic methods and, therefore, as enlarged number of fat cells limits the effectiveness of we calculated body fat from height and dietary therapy in the treatment of obesity. weight. In the obese subjects the two estiFIG. 3. Number fat cells in

cells. estimated the two methods.

of

total number In the obese

mates

of

body

fat

had

a correlation

This is so because fat cells, once formed, coeffiapparently removed very slowly. Indeed fat person with an increased number cells has no way of destroying any currently available medical During weight loss, the size fat pears cells to shrinks, remain but constant. the total Thus, these of

are the of fat by

1.2
C

cells technique. individual when

I.0 0.8

number even to from

apnorthe

w
-j

>

..#{149}

the size of individual fat cells returns mal, the patient is still overweight extra cell mass. The fat cells were at the (Fig. tients and 2) still with 225
EFFICIENCY

0.6
-J Ui U I4 S
S

one obese patient upper limits of 270 this

whose normal pa220

0.4 0.2

Control
FIG.

rIti
cells
by

#{149} #{149}#{149} #{149}

#{149}

weighed cells of

lb. The control size were only

lb.
AND CALORIC EXPENDITURE

Obese

A therapy and
of

second as
number

reason the
of

why sole
fat

the

use of
fat cell

of

dietary is

treatment
body
cells
=

obesity
X 10

2. Volume
of Internal

of fat
Reproduced Medicine.

from
permission

obese

conthe Total 0.92

fat

trol
Annals

patients.

volume

Diet

and

Obesity Table kcal

II.

1145 Thus, a maintenance weekly patient would on considering a weight ensue. kcal/day, a requiring 2,500 be expected to reduction reduced of the calless than diet were the rate of kcal daily, it requires to most us to dethe loss If

for 2 lb.

BODY WEIGHT kg

lose diet.

l,500-kcal

However,

orie requirement, 1 lb./week would reduced to 1,000

OXYGEN CONSUMPTION L/Ar

weight loss would increase still less than 2 lb. a week. considerably produce
4000

to 900 Thus,

greater a meaningful published

calorie weight data from would what

restriction loss than lead has been

currently think. It scribed energy loss.

avenue

is

apparent

DAYS

Fic.

4. Oxygen calorie
of the

consumption

of

six

obese

patients permis-

during
sion

restriction.

FromLancet

by

that any technique for increasing expenditure would accelerate weight Regular exercise provides one such to increasing the caloric deficit. Exwould also appear This finding was by Mayer and his
TABLE
II

Downloaded from www.ajcn.org by guest on February 24, 2012

publisher.

often

unsuccessful

is

related

to the

changes in with calorie

energy expenditure restriction (20,

adaptive that 21). We

ercise take. studies occur noted

to reduce clearly colleagues

food shown (22,

inin 23).

earlier that obese patients require in excess Calculation of 1,100 kcal/m2 to maintain their weight. During calorie restriction this figure drops Classic method so to that obese may patients require on less was a weight-reducing than abruptly 900 kcal/m2 lowered
Total Basal Activity Total Kilocalories diet Daily Weekly Considering of ments kcal) deficit in kcal)

of expected
(1 lb. = 3,500 for

weight

loss

regimen

kilocalorics weight

needed

maintenance 1,700 800 2,500 prescribed 1,500 1 ,000 7,000 require=

maintain weight. After calorie intake

there was a gradual reduction in calorie expenditure that amounted to more than 15% during the 2 weeks of observation (Fig. 4). This food tion the foods. might intake of food so-called The result in simply from that digestion energy dynamic of the the decreased and absorprequirement, action adaptation

kcal/day kcal
=

increases specific time course interpretation, after food consumption

deficit reduced (1 lb. 3,500 for

2 lb.

is
Total

against this first 2 days the oxygen change. quent tance clear.

however. intake was showed

For the reduced little

kilocalories weight

needed

maintenance 1,400 500 1,900 in prescribed 1,500 400 2,800

=

Basal Activity Total

The decline came over the subsedays of the experiment. The imporof this observation to the dieter is It simply means that the usual calories a given basis that loss in the restricted quantity of to produce This is

Kilocalories diet Daily Weekly deficit

for estimating need to be is

underestimated.

illustrated

deficit

0.80

lb.

1146 In

Bray

lead to greater efficiency in the formation of animals and in human beings very low ATP (26). levels of activity actually increased food inThe enzymes in the glycerophosphate cytake, whereas modest degrees of activity from adipose tissue of obese patients seemed to reduce food intake. Thus, increas- cle were about half as active as the enzymes in ing activity in obese patients in spite of the from normal individuals (24). One difficulties has a place in helping to control fat might expect, therefore, that obese people food intake and accelerate weight loss. Obesity calories required. amount tion ories are body, of are occurs ingested These of heat foodstuffs. produced in the that because is greater calories produced The whether body or a correction the than measure during same number the number would of oxidative be more efficient processes to in the coupling formation their of

oxidized provided

Of particular importance for the presthe totalATP. discussion is the effect of calorie restricthe oxida- ent tion on the glycerophosphate cycle. With number of calrestriction there was a further signifithe foodstuffs calorie decrease in the activity of the enzymes outside the cant in the glycerophosphate cycle in adipose is made for

Downloaded from www.ajcn.org by guest on February 24, 2012

tissue from obese patients. To the extent the fact that nitrogen-containing foods are the activity of this cycle is modulating incompletely oxidized in the body. From that the efficiency of food utilization, these obese the physiological point of view, however, it would produce relatively more is not the total number of calories that patients is when eating less. Indeed, it is possible important, but the fraction of these calories ATP the decline in total energy expenditure that can be used for metabolic needs. As that is with calorie restriction may reflect well known, part of the calories produced observed the increased efficiency that could result temporarily decreased activity of this cycle. Since such as ATP. from the activity of the glycerophosphate cycle is When glucose is metabolized, for example, lower in obese patients and declines further a maximum of 45% of the total calories in with calorie restriction, there may, therethis molecule can be converted to ATP. The fore, be some truth in the oft-repeated stateefficiency of metabolic processes in the body ment of fat patients that Doctor, everymay be reduced below this level by several I eat turns to fat. mechanisms, one of which is the glycero- thing during in high metabolism energy are retained intermediates phosphate enzymes logical conversely,
8.0 0 7.0-

cycle. When the activity of these is increased, the efficiency of biooxidations would be reduced, and Since low activity of this cycle would treatment
400

ALTERNATIVE

APPROACHES

dieting

is a safe

but what open? finding

often

ineffective

nues was

for obesity, of therapy are suggested by the

alternative aveOne approach that the glyc-

6.0 5.0-

300

40-

erophosphate cycle was underactive in adipose tissue from obese patients. In experimental animals, the activity of these enzymes are controlled in part by the level of
S-.-

o
3.0200

7
I.0-

[2W=/dJ

______
4000R

thyroid led patients us hormones lowed

triiodoin

hormones to reevaluate in were by period treated reduction calorie of with in obese fed

(25).

This the

observation effects (26). calorie (Fig. 5). these the of Eight diet During subjects With

has thyroid obese fol-

subjects a high intake restriction

000
I

2
PERIOD

FIG. thyronine

5. Effect on

of the cycle

calorie activity in eight

restriction of the obese

and enzymes patients.

the were the the

restricted calorie

triiodothyronine. intake,

glycerophosphate

activity

Be
of the enzymes in the glycerophosphate triiodothyronine the mitochondrial level calorie is the at which intake

and
cywas

0hesty
6.
WILKINS,

1147
L., Diagnosis in A.,
Some and In L. press. W., S. B. GUNNING, AND C.

R. Childhood Ill.:

M. and

BLIZZARD

AND

C. of

J.

MIGEON.

cle declined. added the zyme been started. increased before As

When activity of to the this the low enzyme

The orders

Treatment and 1965, R.

between composition

Endocrine
(3rd ed).

Dis-

Adolescence p. R. 565.

enit had 7. was

Springfield,

Thomas, M. SCHWARTZ,
relationships body

BRAY,
LISTER. sumption tients.

G.

R0zIN
oxygen in

AND

J.
conpa-

rate-limiting activto be increase rise our previin9. in-

obese

one in the glycerophosphate cycle, the ity of the entire cycle would appear creased was total otis of may with the was by accompanied oxygen discussion activity thyroid by consumption. hormones. a corresponding From This

8. KINSELL,
RICHARDSON, do count.

G. 13:

P.

MICHAELS,

J.
Calories

E. Cox Clin.

LENNON.

Metab.

Exptl. Causes,

195, Cost

1964. and The Control.

re-

MAYER,

J.

Overweight: Cliffs, N. A.,

AND

Englewood

J.:
for

Prentice-Hall, MCLAREN-HUME. obesity.

1968, p. 2. Arch. Obesity J.

relatively after

it would appear that of the glycerophosphate to the oxidized.

the level cycle efficiency When as more

10. STUNKARD,
sults of

M.

treatment

Internal treatDietet.
normal dietary re-

Med. 11. G.sv,

ment:

103: 79, 1959. H., AND

results

be inversely related which foodstuffs are activity during of the cycle is the administration efficiency of required ATP. be emphasized is to

D. 1939.

C. KALLENBACH. outpatients.
of and
Sri.

on 212

Am.

Downloaded from www.ajcn.org by guest on February 24, 2012

increased, of triiodoand the these last

it
12.

Assoc.
FELLOWS,

15: 239, H.
in(livi(luals
Ani.

1-I. Studies
(luring

thyronine, substrate quantity It must studies conducted conditions the the doses usual

reduced produce that

obese strictions.
HARVEY,

J. I.,
study

Med. \V.
of the

181: 301, D.
SIMMONS.

1931. Weight
Report reof

same 13. two

H.
a

AND

duction: progress.

group Sci. 227:

interview

method. 521,
or

Am. E. 1197, K. a

J.

Med.
in

1954.
group (us-

with

thyroid hormone under the carefully of a metabolic ward.

have been controlled Moreover, 15. by for

16.

14. MUNVES,
cussion-decision Soc. 29: OSSERMAN,

D. Dietetic
reducing.

I.

Am.

Dietet.
Obesity

Asin

1953. E., AND study Internal N. I. A. L. of H. 0. DOLGER. with

used would be considered large criteria of what is required of hypothyroidism. However, suggest that some therapeutic that have come under recent need reevaluation our search for more with obesity.
REFERENCES

diabetes:
drugs. YOUNG, EINSET obese

therapy

anorexigenic

Ann. C. M.,

Med. 34: 72, 1951. S. Mooiu, Am. Dietet.

reduction-an

treatment they do dalities cism agents of may in

K.BERRESFORD, The problems Assoc. 31:

B. of

M. the

mocriti-

AND B. patient.

G. WALDNER.

1111,

as potential effectiveways

1955. 17. GLENNON, Arch. 18. HIRScH,

lipid obese

J.
Internal

Weight

enigma.

Med. 118:
KNITrLE and adipose cell

1, 1966.
AND L. number tissue.

dealing

J., J.
content human

B. SALANS.
in obese

Cell
and non-

I.

Clin.

Invest. fat

45:

1023, 1. 2. U.
p.

1966. G.
17:

S. Public
19 and

Health M.
social

Service.

Obesity

and L.

Health,

19.

BRAY, Res.

A.
608,

The
1969.

size

of

human

cells. Clin.

20. E.,
class

Mooiu,
Obesity,

A.STUNKARD
and

AND

SROLE.

mental

illness. J.

Am.

20.

BRAY,
expenditure 1968.

G.

A.

Effect
in

of
obese

caloric
patients.

restriction Lancet A. in man

on 2:

energy 397,

Med. 3.
KANNEL, AND

Assoc.
W.

81: 962,
B.,

1962. E. LEBAUER,
Relation

J.
of

T.
of

R. DAWBERT
body weight

P.

M. MCNAMARA. Study. B. A.,

of

21.

GRANDE,

F., of

J.
basal
and

T.

ANDERSON metabolic J. Appl.

AND

KEYS. in 12: semi-

to 4.

development

coronary Circulation B.
obese

heart

disease. 1967. PhysiMAYER.

The

Changes
starvation

rate

Framingham BULLEN,
cal activity

35: 734,

refeeding.

Physiol.

R. by

REED AND
and

J.

230,

1958.

nonobese

adolescent

22. MAYER,
Exercise,

J.,

N.

B.

MARSHALL,

J. J.
AND

VITALE,

J.

H. in nor-

girls
j.

appraised Clin. Nut,-. A-M.,

and

motion 1964. A.

picture

sampling. Am.
Physical

CHRISTENSEN,

J.
food and

H.

MASHAYAHI

F. adult

J.

STARE.

14: 211,
AND human

intake genetically 1954.

AND

and

body obese

weight mice. Am.

5. CHnuco,
activity

J.

STUNKARD.

mal

rats Physiol.

obesity. New

Engi.

J.

Med.

I.

177: 544,

263:

935,

1960.

23. MAYER,

J.,

P.

ROY

K.

P.

MITRA.

Relation

1148

Bray

hormones on L-a-glycerophosphate dehydrogenbetween caloric intake, body weight, and physiwork in an industrial male population in ases and other dehydrogenases in various organs of the rat. I. Biol. Chem. 240: 1427, 1965. West Bengal. Am. I. Clin. Nutr. 4: 169, 1956. of diet and triiodothyronine 24. GALTON, D. J., AND G. A. BRAY. Metabolism of 26. BRAY, G. A. Effect on the activity of sn-glycerol-3-phosphate dehya-glycerol phosphate in uman h adipose tissue in obesity. J. Clin. Endocrinol. Metab. 27: 1573, drogenase and on the metabolism of glucose pyruvate by adipose tissue of obese patients. 1967. Clin. Invest. 48: 1413, 1969. 25. Lsam, Y-P., AND H. A. LARDY. Influence of thyroid
cal

and

I.

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