THE

JOURNAL
VOLUME 1, NUMBER

OF
5

CLINICAL

NUTRiTION
JULY-AUGUST, 1953

Treatment Calorically

of OBESITY

with

UNRESTRICTED
By

DIETS
MI).

I
there that

A. \V.

PENN1NTON,

Downloaded from ajcn.nutrition.org by guest on September 3, 2013

IS

well a level

known a limitation below

that that

weight of the of the

reduction caloric caloric

icintake ex-

SeIVC

stoles.

diet

ate

cornes)on(lingly

sina

11cr of

quires to

intake The

of food. strategic

advantage

of

such

a plan

penditure. by conscious it

This

limitation restraint

of

is usually effected the appetite hut for by brought it so that for individuals, by regulatory are disturbed operate seems at the It reasonbelieving physioto bear weight enforcing the

appears to be reason can also be accomplished

treatment has There appears, advantage to contrast dietary

alone, l)asal is

beell pointed out by Dole et (:1.2 however, to be an even greater this method of treatment, in restriction of the whole for, when carbohydrate, there is no decline in the expenditure.1 When, however,
intake is restricted, a

logical upon is lost caloric

forces which, being the appetite, regulate without restriction. the In necessity normal

to general pattern;
restricted, caloric

the

total

caloric caloric CAroRIc

ox

decline

appetite appears mechanisms; and in the higher obese, level they

to be limited though these continue weight. to

in basal
BASAL

expenditure
EXPENDITURE

is to
OF
DIETS

be expected.
THE OIwsE

of body to

Low

CALORIE

able, therefore, the disturbance intact mechanisms intake to output Evidence has bolic ruvic cessive tween tion treatment composed, striction removing alleviates stance that more
From and Co.,

expect that, if the cause of can be removed, these stillshould adjust the caloric at a normal weight level.1 been presented for a metapathway of by inducing the output; been balance and suggested pyexberest ncas diet Reby acid, subresult a

This
sOfl and!

subject has (;astinetti,3

been who

reviewed by iefer to the

Rynearwork of

Erown and Ohlson4 and of Strang and Evans as showing a (leerease in basal caloric expenditure of the obese on low calorie diets, and to the Muhier such
on

block acid fat caloric

in as

the oxidative a factor which, disturbs and has intake

work and decrease. the

of

Evans Ronys

and and

Strang.#{176} Moller.7 Rony9 as showing were Strang an(1 no based and

Topper,8

storage,

conclusions

expernnents and question rate in reports the and (lecline eight

of Evans of the

of carbohydrate

of

Keeton

Bone.#{176} Rynearson the fall reduction

observes

in a calorically unrestricted essentially, of protein and fat. of carbohydrate, much of the the on the inhibiting oxidation it source of fat, is believed, of pyruvic of this with the

that the metabolic obese finds that the

of the basal of weight of but he lie feels made onan avto

h)CFSOUS

is of some importance; contradictory, and studies have of any

been

influence

insufficient

the energy needs of the tissues, being fully supplied from the bodys own reMedical Wilmington, Division, Del. :343 E. I. du Pont (IP Nemours

permit elusion. Brown

erage

formation Ohlsons

definite showed

studies4

among

of 17 per cent in basal young women of college

calories age: and

344

THE

JOURNAL

OF

CLINICAL

NUTRITION

[Vol.

1,

No.

Strang and Evans, in their a decline of 14 per cent,

than

five
which

cases, was weight

showed greater or surhad

SI(NIFICANCE

OF THE
ENERGY

DECLINE

IN BASAL

EXPENDITURE

the

decline

in

either

the

it diets, intake people would

groups,

was lost

found weight

that after

obese treatment

individuals, by low

who calorie

face latter

area. The investigators

reference to the work of the as showing, also, that no

decline occurs, stems from their introduction of a special formula for calculating metabolic rates from the ideal, rather than from the actual sumption weight-a that fatty method tissue based is on the asmetabolically should not calcula-

maintained considerably

a constant lower

weight on a food than that of other the This two obese intake of

of similar age seem to indicate

there exists

and dimensions.4 that, between

a metabolic

difference

which person

would imist

require subsist

that on

the

formerly

inert and that, therefore, its weight be taken into account when metabolic

a subcalorie

tions are made. The discovery that fatty tissue is metabolically active, however, seems to rule out the validity of metabolic calculations
metabolism

food the rest of his life if he chooses to control his weight by this means. Continuance of suhealoric in fact, diets become after weight reduction recommendation.3 has, a standard

Downloaded from ajcn.nutrition.org by guest on September 3, 2013

based

on

ideal

weights,

method to make hypernormal

of the

calculation

which has been used of the obese appear

It would seem obese persons

individuals

that the situation with formerly is very similar to that of normal

who have accustomed themselves

and its decline on low calorie tageous.3 Examination of the basic data reported no decline in metabolism actually, considered by Moller7 there was significant. showed a decline The a decline

diets

advanwho that,

of those reveals

to a caloric intake below their requirement. In both there would seem to have occurred what Lusk referred to as a specific reduction in metabolism question with it is true, coincident of the greatest use as of low is with undernutriin diets believed, is ion. 12 The connection whether

which was not one case studied of 12.5 per cent of (calculated a decline

significance calorie generally

in basal metabolic from the graph).

rate (B.M.R.) Mulier8 found

only 3.8 per cent in the B.M.R. of 25 children, but pointed out that the pelidisi of Pirquet* is a better standard in this age group than the usual surface area rule. Calculations from the graphs of the eight eases studied Keeton and Bone#{176}show that. there was average decline of 12.2 per They did not consider this the rates did not fall of normal, customarily clinical tests of the however, such note that in below cent. in the significant B.M.R. because

that the reserve stores in an amount sufficient needs of the organism. that
that

of fat are drawn upon to meet the metabolic It might be reasoned rate
tissues

is by an

a fall
the

in basal
requirement

metabolic
of the

means
for

only
energy

has declined, are fulfilled tion, however, mal that less metabolic a decline than

and that their metabolic needs in any case. Another interpretacould be that there is an optirate below for each individual, this rate indicates amount of energy and that is being

the arbitrary limit used in interpreting metabolism. It seems, experiments to take significant inevithere on the

an optimal

physiological

as this it is more appropriate of the actual changes in the The basic seem to that, fall of lQw in in the metabolic calorie
to centimeters a normal

made available for the metabolic work of the tissues. This interpretation would be in accord with Benedicts view that the basal metabolism is a very good index of the general basal of state caloric tests diagnosis gland or level of vital would at the activities.3 to he an level. basal value of diseases very the well range metabexcept be that of error in of the cellular The index As metabolism nutrition interpreted, are rarely and
;14

variables. vestigators dence is a use

*

data give rate

of the various overwhelming adult at attendant least,

appear however, of great

obese diets.

customarily olism the

According in of

Pirquet, is person.

the

cube

of

the

sitting in

treatment and it may practice

height grams

approximately

the

weight

thyroid in ordinary

clinical

July-August

1953]

A.W.

PENNINGTON

345

is

too

wide

for

uses

which question rate reflects

require

greater

should nutrient

be possible
material

for
to

precision. The decline calorie

ment of

the the

tissues to utilize maximum extent would calories would

this of then for

answer diets

to merely

the

whether obese on require-

the low

in metabolic

of the

which be no performing and no

expected.

they are question the decline This,

capable. There of a shortage of metabolic in metabolic is the is treated in which it seems, work rate

a lessened

of the situation

tissues, be pro-

whether are not tate an mental bolic answer oxidize

the tissues, or, on the other hand, it signifies that the tissue requirements being inquiry matters the the fulfilled, would seem to necessifundaMetato into some of the most in metabolic theory. in its question: amount broadest scope,

duced when obesity unrestricted diets alone, is limited. A diet

fat is ketogenic.

by calorically carbohydrate, of protein and is

theory,

attempts

co#{241}sisting essentially
Ketogenesis,

what causes the body to of nutrient materials that on the Rubners matter concept
has

the
tities zation

normal
than

mechanism
to utilize fat

by
in

which
much

it appears, the organism

larger quan-

it does? Current thought l)een largely colored by

is enabled furthermore,

of

it
is

otherwise
followed acids the fatty tissues from

could.8
by the increased adipose

Ketonemia,
mobihitissues.9

Downloaded from ajcn.nutrition.org by guest on September 3, 2013

a rigidly fixed caloric expenditure, determined by the requirement; this in turn is determined by the surface area of the body. This cofleel)t was opposed vigorously by Rubners teacher, Voit, who insisted that, while the tissues have a certain foodstuffs, maximal capacity the am o u ut they for metabolizing actually me tahothe qualto them cause of

of fatty and the

Consequently, ketones causing

blood
acids to

concentration
becomes oxidize would

of both
increased,

them
seem and

in
to

larger
be the

amounts.61
Ketogenesis, therefore,

lize is influenced by the quantity and ity of the nutrient materials brought by Voit the blood.2 said, cannot The requirement possibly be the

key have whom

greater

to

the special the

possibility
unrestricted

of weight
diets;

reduction

on

calorically

for energy.

applicability

to

this would the obese, in

metabolism any more for gold will put it into concept of the metabolism support zation by the in studies of glucose,15 tissues which fatty

than the requirement ones pocket. Voits would seem to find show acids,16 by in that and the the utiliketonesT concentia-

ketogenic response to fat feeding is than it is in the lean.2#{176} A greater than quota of upon the the energy tissues requirements by fat to the indeposits, a correin which into the adjusturged

ordinary would be

creased mobilization and the appetite sponding

nutrient

of the bodys would decline Animal are indicate experiments introduced a very

is influenced

extent.
materials

tions of these substances decline in metabolism weight reduction by low might reserve bilized needs reasonably stores of

the blood. The of the obese during calorie diets, therefore. the mo-

drinking

water

precise

be taken to indicate that body fat are not being to meet the metabolic

ment in the seems that whether the

voluntary caloric intake21 and it the effect would be the same nutrients were added to the metathe of then, bodys an inwould effecting intake and for weight is used, according the to day. for and

rapidly enough of the tissues.

OF FAT WEIGHT

bolic pool from without or from own reserve stores. Mobilization creased quantity of utilizable fat, be the of limiting factor on the appetite, the disproportion between caloric expenditure which is necessary reduction. When actual such caloric a plan intake of treatment would vary

STIMULATIoN

UTILIZATION REDUCTION

DURING

It would the an fat, ity

upofl

seem

desirable

in the

treatment

obese to direct measures increased mobilization instead of relying upon of be caloric the adipose stimulated of fat restriction deposits. to oxidation to

primarily toward and utilization of the dubious abildraw If fat adequately mobilization degree, be reduced, and it

the needs of each This appears to daily other variations factors affect

individual from day to be a great advantage, in physical the energy activities requirements;

can

a sufficient can

inhibition

346 and for weight under loss these furnish required to would circumstances

THE proceed

JOURNAL in the any adipose

OF CLINICAL case, tisof the leaving The for been UI) because

NUTRITION there is at least one report

[Vol.

1, No. sug-

which

sues, first, nutriment the appetite large caloric maintaining eniphasized. to 4500 nothing when some weight ler day. this obese on

a considerable quota by the organism, make up time remainder. of that the must, of 3000 the have they

gests that the by this means.23

metabolism may Salt, as is well

be increased known, often

requirements constant weight Evans found a day.3 in

obese often range

causes fluid retention, and this may exist. in a subclinical degree more often than is realized!. The clinical inhl)ression is gained that, with some individuals at least, salt interferes with weight loss on calorically unrestricted diets to
all

calories remarkable method

There is, therefore, observation that, obesity of necessity, calories is use(l, lose or more

water

extent not explainable by the which may be retained. general hygienic regimen including regular rest, A half-hour walk,

weight

of the

of treating

individuals an intake

A vised, slee)ing.

has been adwithout overequivalent

or the

PRACTICAL

APPLiCATION OF

METHOD in mum mended the of practical 8 ounces for each

OF THIS TREATMENT a minirecomday; is of

exercise, before breakfast. also has been recommended. The reason for this is that, while 60 per cent of the energy needs of the body night exercise are supplied by fat fast, the l)Ioportion in the post-absorptive after can the usual be increased state.5 by calorically depends upon use of fM have to by the overby The uneffecor-

Downloaded from ajcn.nutrition.org by guest on September 3, 2013

use of of the that part

of this method meat has been three meals

of the

entire success of treatment restricted diets, it seems, tively ganisni. Since readily following matters has stimulating th obese the patient

and to emphasize to be eaten, one lean meat proportion. has

fat, as well as lean, of fat to three parts the proper proportion meat

been suggested as This is the general when an exclusive

must guide been of

a concise. go by, the the and four

understandable set

adopted by choice has been followed.22 Carbohydrate amount calculated genesis. Peters hydrate amount viduals.23 would seems The

diet

sheet of instructions, forth above, has satisfactory

embodying prepared the past

has been allowed in an not to interfere with ketofound that 100 Gm. of carboreduce to very ketogenesis,18 vary in low calorie but. time different indidiets of Strang 40 Gm. of carboand these diets protein-sparing patients on a calorically pci cases ac-

proved

during

veams. Like most sheets tions, its form is didactic: tient is likely to become points. question present it has ?principle diet

dietary otherwise indecisive

instructhe paon many

and Evans, containing only hydrate, were ketogenic,24 showed tion. In unrestricted day have a very most favorable of the

Although some may find reason to certain details, it has seemed best to it in its entirety, in the form in which been effectively used. The essential on which a calorically unrestricted appears to work-that of sufficiently difone the oxidation that of low of fat-is quite calorie diets; and it is to establish the use that quite the use its fate on W. of low matmadof a efof a

diet, 60 Gni. of carbohydrate been allowed, although in a few

stimulating ferent from

a more drastic reduction has Since most patients, though with calories, are not familiar in helpful an tity of carbohydrate, foods, it has seemed of a few 20 Gm. Liberal lowed. value eases foods containing of carbohydrate Salt

seemed necessary. they are familiar with the quanvarious a list of about serving. althe disalso grams, in to provide average

of the chief tasks the new orientation. Reasoning calorie diets ters applicable vertently calorically fectiveness. the calorically be has

in applying with

associated

been so ingrained to such diets can over it diet, seems, into

carried

in an ordinary

amounts of water has been restricted, treatment with

have been both for of certain obesity, and

unrestricted Such,

impairing was the diet based

unrestricted

of this in the often associated

concept of obesity as a defect of carbohydrate metabolism, devised by the physician,

July-August

1953]

A. W. PENNINGTON reflections upon the lectures of Liebig, the diet underwent a suceesion features Finally, it lost diets calorically use

347

Harvey, Claude Harveys

from Bernard, diet,

of

which he attended in which attempted to avoid specifically, amounts,

1856.26 sweet

modifications, which conformed as the modified identity among time nineteenth The sheet unrestricted ing the past diet four

retaining only those to current theory. Banting the many century. low for diets, calorie the

and starchy meat in ad

foods, libitum

while allowing met with wide-

its of

spread success2 and had! a permanent influence on the treatment of obesity. However, since certain details of the diet could not find a rationale in the prevailing physiology of A With itself. sleep,
fore

of instructions which years28

been in is as follows:

has

(lur-

DIET

FOR

OBESITY

this Have

diet

you

follow hour

a definite for going

routine to bed. allow fast,

which Set your

is as alarm

important clock for

as

the

diet hours befull a fat. is not

a regular

eight

never breakfast.

a minute more than It is not necessary

that, and to walk

time for a thirty-minute walk but it is necessary to walk the You eat three meat want. meat make lamb you big with The buy up the chops, grind meals the

Downloaded from ajcn.nutrition.org by guest on September 3, 2013

thirty minutes regularly. Breakfast, lunch, and dinner are all the same type. day and lose seven pounds of excess weight a month. First course of each meal: One-half pound or more This part of the is three so get Good pork, diet is unlimited. parts extra meats and pork of lean beef are kidney roast You to one can part eat fat. slice steak, as much Most proportion fat enough, proportion. beef, just use Do as soup, bologna, Second meal you potatoes, fresh before paprika, not

of fresh as you of the

propel propel stewed

fat, beef, Hamburger

and fry it to roast lamb, is all right

chops.

if you

it yourself

it is cooked. Season the meat celery seed, lemon, chopped which use does time least not contain salt. of salt. Do particle

with black parsley, not use

pepper before it is cooked or or celery tops, or use other foods which contain salt, salt, frankfurters. At each white a Do only mensuch

flavoring

bacon. canned

smoked ham, canned chicken, or fish or spiced meat, or salted butter. part

containing

course of each meal: This have a choice of an ordinary sweet potatoes, boiled rice,

of the diet is strictly limited. portion of any one of the following: grapefruit, coffee day before grapes, or tea five slice without oclock. else of

half

melon,

banana, a pear, raspberries At the end of each meal not Be use saccharine. to drink six glasses sure

or blueberries. have a cup of black of water in a glass flour, salt, every

sugar. Your not

other beverage is half a lemon This diet contains no bread, tioned.

of water if you desire it. sugar, alcohol, or anything

SUMMARY

Restriction of to make possible calorically of protein and petite, necessary fat.

carbohydrate, the treatment diet The to any limiting treatment

alone, appears of obesity on a composed chiefly factor on apof obesity,

unrestricted

the homeostatic forces which normally late the appetite. Ketogensis appears key factor in the increased utilization Treatment of obesity by this method to avoid tered tails the decline in the metabolism in treatment of diet and by caloric restriction. regimen are given.

reguto be a of fat. appears encounDe-

appears to be provided by tion and utilization of fat,

increased mobilizain conjunction with

348

THE REFERENCES

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OF CLINICAL
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