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TH E A M ER IC AN JO URN A L O F Cl in ica lSEPTEM BER 1970

Nutr i t ionVO LUM E 23 #{149}N U M BER 9

G uest E d ito ria l

The M yth o f D ie t in th e M anagem en t#{149 } 123o esity

GEORGE A . BR AY

O BESITY IS A W IDESPR EA D M ALAD Y in oursoc iety , ye t its und erly in g cause still

elu des m ed ica l s cience an d its the rapy is ,therefo re , em p iric al. M any th erap eu tic ap-proache s have b een trie d in clu d in g d iets ofa ll k inds , to ta l an d in term itten t s tarva tion ,hea lth spas, ex erc ise m ach in es , and m ed ica-tion o f va rio us types. R ecen t in fo rm a tionprov id es som e ins igh t in to th e g en era lly d is-appo in ting resu lts th at have b een ob ta inedusing a d ietary approach .

O besity ex ists w h en fat m akes up agreater th an no rm a l fract ion o fo ta l b odyw eig ht. O v erw eig h t, on th e other hand , isde fin ed in rela tion to tab les o f idea l w eig h tth a t h ave usu ally been prepa red by life in -su rance com pan ie s. It is fair to say tha tob ese p eo p le a re usua lly ove rw e igh t, bu tth a t no t a ll o ve rw e igh t peop le are o bese.S in ce it is ea sy to m easu re w e igh t, b u t m ored ifficu lt to quan tita te fatn es s , m o st o f theep idem io log ica l da ta im ply ing tha t o besityis a haza rd to hea lth a re in fac t de rivedfrom stud ie s o f ove rw e igh t. W hen theabn orm ali ty in w eig h t exc eed s the idea l fo rhe igh t and ag e b y m ore than 3 0% in the

F rom th e N ew E ng lan d M ed ica l C ente r H os-p ita ls an d D epar tm ent o f M edicine, T uf ts U ni-versity Sch oo l of M edic ine , B o ston , M assach use tts .

Su ppo rte d by N atio nal In sti tu te s of H ealthG ran ts A M 09897 and lR-52 .

B a sed on a lec tu re g iven to the N ew Englan dD airy C ounc il, A pr il 1 , 1 97 0 .

nonath iet ic in d iv id ua l, ov erw eig h t is a lm os tas su red ly d ue to ex cess fa t. T h e p reva lencean d sig n ifican ce of ob esi ty c an be st be con-v eyed from the fo llow in g sta t ist ics. Th eU nited S tate s P u b lic H ea lth Se rv ice ind i-ca tes tha t 25 -4 5% o f th e adu lt A m ericanpopu la tion ove r 30 y ea rs o f ag e is m o re than2 0% ov erw eig h t (1 ) . In ch ild hood , o besity ,d ef ined as 40% or m o re abo ve the m ed ianw e igh t fo r he igh t, o ccu rred w ith an in ci-d ence of 2-1 5% (1). Th is bu rd en is no tbo rne eq ua lly am ong a ll s egm en ts o f soc ie ty .A stu dy in M anh atta n ha s show n tha t ob e-sity is 7 tim e s m o re comm on inhe low estso c ioeco nom ic grou p as com pared w ith theh ighest g rou p (2 ) . T he m ed ica l im portan ceo f co rpu len ce is clear from the inc rea sedm orta lity an d m o rb id ity a sso ciated withoverweigh t . In the F ram in gham S tu dy offa cto rs rela te d to h ear t d isea se , obe se sub -jects w ere m o re p ron e to an gin a p ectorisand to su dden death th an w ere p eo p le o fno rm al w e igh t (3 ) . In ad d ition , d iab ete sm e llitu s , g all b lad de r d isea se , and re sp ira -to ry d isease a re a ll m ore comm on in th eov erw eig h t p atie n t.

R AT IONALE FOR D IETAR Y M ANAGEM ENTO F O BESITY

In the sim p les t term s, ob esity occu rs b e -cau se th e calo ric v a lue o f ingested foo d isgreater than the da ily req u irem en ts . E xcess

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ca lo rie s no t u sed each d ay a re conv erted tofa tty ac ids and a re sto red in ad ipose tissu ece lls because th is s ite can be expand ed a l-m ost w ithou t lim it. E xcess fa t can accum u-late in pe rsons con tin u ing n orm a l foo din tak e if ene rgy exp en d itu re is red uced . E v i-d en ce fo r th is m echan ism in obese teenageg ir ls ha s been presen ted by B ullen and co l-leag ues (4 ), w ho u tiliz ed m otio n p ictu re s todo cum en t th at ob ese g ir ls w ere m easu rab lyle ss ac tive than th e ir th in co n tem po ra rie s .C h ir ico and S tu nka rd (5 ), u sin g pa irs o fob ese and lean sub jec ts o f the sam e sex an doccupat ion , sh owed tha t activ ity w as le ss inthe obese m em ber o f m ost pa irs . T h e m oststr ik ing exa lnp ie o f o besity due to reduceden ergy outpu t, h ow ever, w ash e repo rt b yW ilk in s and h is co -w orke rs from th e Jo hnsH opk ins H osp ita l (6 ) . T h ey reported a 6 -year-o ld ch i ld w ho b ecam e a lm o st com -p lete ly pa raly zed an d ga ined weigh t when -ev er da ily in tak e ex ceeded 500 kca l.

A secon d w ay in w hich an im ba lance be -tw een ca lo rie in tak e and expend itu re canoccu r is b y inc rea sin g foo d consum ptio nw hile m a in ta in ing no rm a l ac tiv ity . T olea rn w he the r ca lo r ie in take w as exces siveo r en ergy ex pend itu re d im in ished , w e quan-titated th e ene rgy ex pend itu re o f a g ro up ofg ro ssly o bese adu lt pa tien ts (7 ) . M easu re -m en ts o f ox ygen con sum ption w ere m adeand u sed to ca lcu la te ene rgy need s. S am -p ie s o f exp ired air w ere co llected o n eachpa tien t sev e ra l tim es a day fo r a p e riod of6 -12 days and ana ly zed fo r the ir con ten t o foxy gen and carbo n d iox ide . E ne rg y ex -pend itu re has b een m easu red b y th is tech -n iqu e in m o re than 30 obese pa tien ts . Ingene ra l, heav ie r pa tien ts hav e grea te r re -qu irem en ts fo r o xy gen . To ta l ox ygen con-sum p tion (en ergy ex pend itu re ) am ong pa -tien ts had a h igh corre la tio n w ith to talb ody fat, su rface area, and b ody w e ig h t bu ta m uch le ss sign ifican t co rre la tion w ithm easu re s o f lean b ody m ass, such as to ta lb ody w a te r, exch an geab le p o ta ssium , an dc rea tin ine exc re tion . T he da ta re la ting oxy -gen con sum ption w ith su rface a rea in 1 8 o f

our o bese pa tien ts had the slop e of 1 ,1 00kca l/m 2 (7 ). T h is m eans tha t fo r each ad d i-tio na l squ are m e te r o f su rface area an ex tra1 ,10 0 kcal, on the ave rag e , is requ ired just tomaintain body w e igh t. T h is re latio nsh ipb etw een oxyg en con sump tion and su rfacea rea in obese pa tien ts is e ssen tia lly th e sam eas the o ne fo r lean in d iv id ua ls , ind ica tingtha t ob ese an d lean peop le h av e th e sam eca lo rie requ irem en t pe r un it su rface area.F rom th is in fo rm a tion w e can calcu la tetha t, to ga in w e igh t, an in d iv id ua l w ith asu rface a rea o f 2 m 2 w ou ld requ ire in exces so f 2 ,2 00 kcal d aily . A s m o st o f o u r obese pa -tien ts w ere be tw een 2 and 3 m 2 (co rrespon d-ing to 2 50-45 0 lb .) , a d ie t co n ta in ing 3 ,5 00kca l sho u ld p rod uce on ly a sligh t w e igh tga in in in d iv id ua ls in th is g ro up .When weplaced six ob ese p atien ts o n a d iet o f 3 ,50 0kcal fo r 1 w eek , the re w as no sign ifican t in -c rea se in w e igh t, th us supporting o ur con-clu sio n tha t o bese p atien ts req u ire a la rgen um ber o f calo rie s to m a in ta in w e igh t an dev en m o re to ga in w e ig h t. C onv erse ly , w ew ou ld exp ec t th a t if re str ictio n o f calo rie in -take w ere adequ ate , w e igh t lo ss w ou ld en -sue . T h is fac t has been dem onstrated m anytim es (8 ) .

RE SULT S OF CA LOR IE R E STR ICT IO N IN THEM ANAG EM ENT O F OBESITY

C lin ic s em ploy ing d ieta ry m anagem en t inthe trea tm en t o f ob es ity have gene ra llyach ieved poor re su lts . S tu nka rd and M c-L aren -H um e (10 ) rev iew ed the ex pe rienceo f a n um ber o f n u tr ition c lin ic s th at havetrea ted ob esity , an d som e of th ese da ta h av ebeen summ arized in F ig . 1 . T he n um ber o fpa tien ts in each study is show n a t the bo t-tom of th e figu re and the pe rcen tage of pa -tien ts ach iev in g a w e igh t lo ss o f 2 0 or 40 lb .is show n by th e h eig h t o f th e b ars . Th erew as som e va riab ility from on e stud y toan o the r , bu t in gene ral the pe rcen tag e lo s-in g 20 lb . o r m ore w as le ss than 30% (m ean= 24% ). W hen on e look s a t th e pe rcen tageach iev ing a 40 -lb . w e ig h t lo ss the ou tlo ok iscon side rab ly le ss sa tisfac to ry . H ere the av er-

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D ie t and O besity 11 43

Mo d i f i e d f r o m t h e d a t a o f Yo u n g e t a l . ( 1 6 ) .

50

40

0W E 1G I4 I LO S S M O R E IRAN 2 0 P O UN D S

W E HT L O S S M O P E IR A N 4 0 P O uN DS

4.2 30

H1L{ E L 1 L r k I314 294 29 0 46 so 131 100

N UMB ER O F P A T IENTS

F IG . 1 . Weigh t loss in patien ts t rea t ed with diet .N um ber of pa tien ts in each s tudy isisted belowea ch pa ir o f b ars an d th e perc en tag e lo s in g 20 or40 lb . is in dica te d by the heigh t of th e bars . Th ere fer en c es fo r co lum ns 1-7 , reading from left torig ht are 1 1 , 12 , 13 , 14 , 1 5 , 16 , 10 .

ag e w as on ly 9% . Such a m e thod o f p resen t-in g d a ta o n w eig h t lo ss has its lim ita tions.T he re are a lw ays pa tiem s fo r w hom aw e igh t lo s s o f 2 0 o r 4 0 lb . w ou ld b rin g th emvery c lose to the ir desired w e igh t and o the rpa tien ts fo r who in such w eig h t lo sse s wou ldbe triv ial. T o m ak e som e co rrec tio n fo rthese facto rs , Y oung e t al. (1 6 ) eva lua tedw e igh t lo ss in rela tion to the am oun t o f ex -ces s w e igh t. T hus, pa tien ts w ere d iv idedin to s ix groups an d the successe s eva lua tedin re la tion to the w e igh t to be lo st.it h in -creas ing in itial w eig h t, th e success rate fe ll,ye t it is the heav ie r pa tien t fo r w hom w eig h tlo ss is m ore im portan t (T ab le i).

T hese o bse rv atio ns ind ica te tha t d ie tarytrea tm en t o f o besity is m ore like ly to suc -ceed in p a tien ts w ho a re on ly m odestly ove r-w e igh t. F o r these pa tien ts the com pan ion -sh ip o f sim ila rly a ff lic ted ind iv idu als m ayprov id e an add itio na l incen tive to losew eig h t. It is th is tech n iqu e th at such gro upsas the TO PS (Take O ff Pound s S ensib ly )C lub s have used w ith rep orted su ccess. S ev -e ra l o th e r g rou ps, inc lud in g D iet K itchen ,D ie t W orkshop , an d W eigh t W atch ers , h avead ded an add itio na l m one ta ry incen tive tow eig h t reduc tion b y d ie ta ry m eans . In pa -tien ts w ith m arked obesity , h ow ev e r, theo u tloo k w ou ld ap pear b leak fo r any of th esem e thod s. In a fo llow -u p stud y o f 19 9 p a-tien ts w ho w ere 5 0% o r m ore o ve rw e igh t,G lennon (17 ) fo und th at on ly on e m d i-

v id ua l approached no rm al w e igh t, ano the r12% w ere ab le to ach ieve a w e igh t lo ss o fm ore than 20 lb . bu t on ly 6% lo st m oreth an 40 lb .

Un for tun ate ly , fo r th e obese p atien t eachn ew d iet p rod uces its tem po ra ry w e igh t lo ss ,b u t th is is u sua lly fo llow ed by a re lapse ,w ith w eig h t re tu rn ing to th e sam e o r h ighe rleve ls . M aye r (9 ) has ap tly desc r ib ed th is as the rh y thm m eth od of g irth co n tro l. Ifthere w as an e ffectiv e d ie t, the re w ou ld be n on eed fo r the con tinuo us in tro duc tion o f newdie ts : the G rape fru it d iet, th e D rink ingM ans d ie t, th e A ir F o rce d ie t, theM ayo d ie t, th e Q u ick W eigh t Loss d ie t,an d so on . I t seem s obv io us from th e num -b e r o f d ie ts tha t h av e been m ade av ailab lean d a re co n tinu ing to app ea r , n one of themp ro v ides the an sw er to ob es ity .

ADIPOSE CELLS IN OBESITYTw o areas o f in vestiga tion have p ro v ided

a pa rtia l exp lana tion fo r th e fa ilu re s o fca lo rie re stric tion in the trea tm en t o f o be -sity . A cc retio n of fat can occur b y eith er en -la rg ing the ex isting fat ce lls to accomm oda tethe ex tra fa t, in creas ing the to ta l num ber o ffa t cells , o r b y a com bin atio n of bo th (18 ) .W e have m easu red the size o f subcu tan eo usfa t ce lls und er a m icroscop e a fte r d ispe rsingth e cells by incub atin g th em in co llag en ase(19 ). The size o f subcu tan eo us fa t cells in a

TABLE IW eight red uction in rela t ion to in itia l

weigh t5C riter ia o f N um ber of su cce sse s

In itia l w e igh tra nge, lb .success( p o und s

to b e lo st) T o ta l n um ber %

Under 1 5 0 1 0 1 1 / 2 5 4 41 5 1 - 1 7 5 1 5 1 1 / 3 6 3 11 7 6 - 2 0 0 2 0 1 3 / 4 7 2 82 0 1 - 2 2 5 2 5 3 / 2 2 1 42 2 6 - 2 5 0 3 0 1 / 1 5 7Ov e r 2 5 0 3 5 2 / 1 1 1 8

To t a l 4 1 /156 2 6

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rItiC o n t ro l O b e s eF IG . 2 . V o lum e of fa t cells from obese an d con -

tro l patien ts. R ep ro duced by pe rm ission o f theA nna ls o f In tern al M edicin e.

1144 B ray

group of ob ese an d con tro l pa tien ts is show nin F ig . 2 . S ub cu taneous fa t ce lls from thecon tro l su b jec ts (p atien ts u nde rgo in g lapa -ro tom y) w ere abou t one -th ird th e size o f th efat ce lls from the o bese sub jec ts . Ind eed , theo ne fa t pa tien t w ith the sm alle st ce lls hadlo st 12 0 lb . p rio r to h is b iopsy . F rom th iscom parison w e w ould con clu de tha t ob esep atien ts have cons ide rab ly large r sub cu-taneou s fa t cells than con tro l su b jects . Inthe con tro l g roup the re w as a p ositive co rre -lat ion (P < 0 .0 5 ) be tw een th e v o lum e o f fatce lls and body w e ig h t. T hu s, w e w ou ld con -c lude tha t h eav ie r p atien ts had la rge r fa tcells and tha t the accum u la tio n of fa t is ac -com pan ied in p art b y en la rg em en t o f subcu-tan eo us fa t ce lls .

W e h av e es tim a ted the to ta l num ber o ffat cells by tw o m ethod s. In th e ob ese p a-tien ts w e m easu red th e to ta l bod y w ate rfrom the d is tribu tion of tritia ted w a te r andused th ese da ta to ca lcu la te the to ta lam oun t o f fa t (7 ) . In the co n tro l p atien ts itw as no t pos sib le to m easu re the ir to ta l bo dyw a te r b y iso top ic m e thod s and , the re fo re ,w e calcu la ted bo dy fa t from he igh t andw e igh t. In th e ob ese sub jec ts the tw o esti-m a te s o f bod y fa t had a corre la tion co effi-

CONTROL OBES EF IG . 3 . N um be r of fa t cel ls in contro l an dobesepat ien ts .

cien t o f g rea te r th an + 0 .90 (P < 0 .01 ). W eh av e assum ed tha t su bcu taneou s fa t ce llsa re rep re sen ta tive o f all fa t cells .4 I t w ou ldapp ear tha t m any gross ly o bese in d iv id ua lsh av e an inc reased n um ber o f fa t ce lls as w e llas en la rged fa t cells (F ig . 3 ). T he inc rea sedn um ber o f fat ce lls lim its th e e ffec tiv en ess o fd ie tary th erapy in th e trea tm en t o f obesity .Th is is so b ecause fa t ce lls , on ce fo rm ed , areap pa ren tly rem oved ve ry slow ly . Ind eed thefa t p e rso n w ith an inc rea sed num ber o f fa tce lls has n o w ay o f d estroy ing these ce lls b yan y curren tly ava ilab le m ed ica l techn iq ue .D u rin g w e igh t lo ss , the size o f ind iv idu a lfa t ce lls sh rin ks, bu t the to tal n um ber ap -pea rs to rem a in con stan t. T h us, ev en w henth e size o f ind iv idu al fat ce lls re tu rns to no r-m a l, the p atien t is s till ove rw e igh t from theex tra cell m ass. The one o bese pa tien t w hosefa t ce lls w ere at the upp er lim its o f n o rm a l(F ig . 2 ) still w e igh ed 270 lb . Th e con tro l pa -tien ts w ith ce lls o f th is size w ere o n ly 2 20an d 225 lb .

E FF I C I EN CY A ND CA L OR I C EX PEND I T U REA second reason w hy the u se o f d ieta ry

the rapy as th e so le trea tm en t o f ob esity isbody fat X 10 To t a l num ber of f at cel l s = 0 .92 fat cell vo lum e

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B ODYWEIGHT

kg

DAYS

Calcu lation o f ex p ec ted w eig h t lo ss

Cl a s s i c me t h o d ( 1 l b .= 3 , 5 0 0k c a l )

To t a l k i l o c a l or i c s n e e d e d f o rwe i gh t ma i n t e n a n c e

B a s a lAc t i v i t y

T o t a l

Ki l o c a l o r i e s in p r e s c r i b e dd i e t

Da i l y d e f i c i tWe e k l y d e f i c i t

Co n s i de r i ng r e d u c e d r e q u i r e -me n t s ( 1 l b . = 3 , 5 0 0k c a l )

To t a l k i l o c a l or i e s n e e d e d f o rwe i gh t ma i n t e n a n c e

B a s a lAc t i v i t y

T o t a l

Ki l o c a l or i e s i n p r e s c r i be dd i e t

Da i l y d e f i c i tWe e k l y d e f i c i t

1 , 7 0 08 0 0

2 , 5 0 0

1 , 5 0 0

1 , 0 0 0 k c a l / da y7 ,000 k c a l = 2 l b .

1 ,40050 0

1 ,900

1 ,500

D ie t an d O besity

40 02 ,800 = 0 .8 0 lb .

OXYGENCONSUMPTION

L/Ar

4 0 0 0

Fic . 4. O xygen consum pt ion of six obese p at ien t sdu ring calo rie res tric tio n . FromLance t by permis-sion of the p ub lish er.

of ten u nsu ccessfu l i s r elated t o th e adapt ivech an ges in energy ex pend itu re that o ccurw ith calo rie re strictio n (20 , 21 ). W e no tedearlie r that o bese p atien ts requ ire in ex ce sso f 1 ,10 0 k cal/m 2 to m ain tain th eir w e igh t.D uring calorie restric tion th is f ig ure dropsso th at obese p atien ts on a w e igh t-red uc ingreg im en m ay requ ire le ss than 9 00 k cal/m 2to m ain tain w eig h t.

A f te r calo rie in tak e w as abrup tly low eredthere w as a grad ual red uc tion in calorie ex -pend itu re th at am oun ted to m ore th an 15%during the 2 w eek s o f ob se rv atio n (Fig . 4 ).T h is m igh t resu lt s im p ly f rom the d ecreasedfo od in tak e in that d ig estio n and absorp -tio n o f f oo d inc rease s en ergy req u irem en t,th e so -called sp ec if ic dy nam ic actio n o ff oo ds. T h e tim e cou rse o f th e adap tation isag ain st th is in terpre tatio n , how ev er. Fo r th ef irs t 2 day s af te r f ood in tak e w as reducedthe ox y gen co nsum ptio n show ed littlech an ge . T h e dec line cam e ov er the subse-quen t d ay s o f th e ex perim en t. T h e im por-tance o f th is o bse rv ation to the d iete r isc lear. It s im p ly m eans that the u sual basisf o r e stim ating th e q uan tity o f calo rie s th atneed to be restric ted to prod uce a g iv en lo ssis u nderestim ated . T h is is illu strated in

1145

Tab l e I I . T hu s, a p atien t requ iring 2 ,500k cal f o r m ain tenan ce w ou ld be ex pec ted tolo se 2 lb . w eek ly on a l,500 -k cal red uc tiond iet. H ow ev er, con side ring the red uced cal-o rie requ irem en t, a w eig h t lo s s o f les s than1 lb ./w eek w ou ld ensue . If th e d ie t w erereduced to 1 ,000 k cal/d ay , the rate o fw e igh t lo ss w ou ld in crease to 900 k cal d aily ,s till less than 2 lb . a w eek . T hu s, it requ ire scons ide rab ly greate r calo rie res tric tion toprodu ce a m ean ing f u l w eig h t lo s s than m ostcurren tly pu b lished data w ou ld lead us tot h i nk .

It is ap paren t f rom w hat h as been d e-sc ribed that any techn ique f o r inc reasingen ergy ex pend itu re w ou ld acce le rate w e igh tlo ss . R egu lar ex e rcise prov ide s one suchavenue to increasing th e ca lo r i c d ef ic it. E x -e rcis e w ou ld also app ear to red uce fo od in -tak e. T h is f in d ing w as c learly sh ow n ins tud ie s by M ay er and h is co lleagu es (2 2 , 2 3 ) .

T A B L E II

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8.00

7 . 0 -

6 .0

5 .0 -

40 -o

3 .0 -

7 I. 0 -

40 0

8 30 0

20 0

_ _ _ _ _ _0 0 0 R [ 2W= d J00 0

I 2 3

S - . -

P E R I O D

F IG . 5 . Ef f ect of calorie restri ction and tri iodo-thyronine on the act i v i ty of the enzymes in theglycerophosphate cy cle in ei ght obese patients.

1146 Bray

In animals and in human beings very lowlevels of a ctiv ity actually increa sed f ood in-take, w hereas modest degrees of acti v i tyseemed to reduce f ood intake. T hus, increas-ing acti v i ty in obese patients in spi te of thedi f f i cul ti es has a place in helping to controlf ood intake and accelerate w eight loss.

Obesi ty occurs because the number ofcalor ies ingested is greater than the numberrequi red. These calories measure the totalamount of heat produced during the ox ida-ti on of foodstuf f s. T he same number of cal -ories are produced whether the f oodstuf f sare ox idi zed in the body or outside thebody , prov ided that a correcti on i s made f orthe fact that ni trogen-containing f oods areincompletel y ox idi zed in the body. Fromthe physiological point of v iew , how ever, i ti s not the total number of calories that isimportant, but the f racti on of these calor iesthat can be used for metabol i c needs. A s isw el l know n, part of the calor ies producedduring metabol i sm are retained temporari l yin high energy intermediates such as A TP.W hen glucose is metabol i zed, f or example,a max imum of 45% of the total calories inthi s molecule can be converted to A TP. Theef f i ciency of metabol i c processes in the bodymay be reduced below this level by severalmechanisms, one of w hich is the glycero-phosphate cycle. W hen the acti v i ty of theseenzymes is increased, the ef f i ciency of bio-logi cal ox idations w ould be reduced, andconversely , l ow acti v i ty of thi s cycle w ould

lead to greater ef f i ciency in the formation ofA TP (26).

T he enzymes in the glycerophosphate cy-cle f rom adipose ti ssue of obese patientsw ere about hal f as acti ve as the enzymes inf at f rom normal indiv iduals (24). Onemight expect, theref ore, that obese peoplewould be more ef f i cient in coupl i ng thei rox idati v e processes to the formation ofA TP. O f parti cular importance f or the pres-ent di scussion is the ef f ect of calor ie restri c-ti on on the glycerophosphate cycle. W i thcalor ie restri cti on there w as a f urther signi f i -cant decrease in the acti v i ty of the enzymesin the glycerophosphate cycle in adiposeti ssue f rom obese patients. To the extentthat the acti v i ty of thi s cycle i s modulati ngthe ef f i ciency of f ood uti l i zati on, these obesepatients would produce relati v el y moreA TP when eating less. Indeed, i t i s possiblethat the decl i ne in total energy expendi tureobserved w i th calorie restri cti on may ref lectthe increased ef f i ciency that could resul tf rom decreased acti v i ty of thi s cycle. Sincethe acti v i ty of the gly cerophosphate cycle i slow er in obese patients and decl i nes furtherw i th calor ie restr i cti on, there may , there-fore, be some truth in the of t-repeated state-ment of f at patients that D octor, every-thing I eat turns to f at.

ALTERNATIVE APPROACHES

Since dieti ng i s a saf e but of ten inef f ecti v etreatment for obesi ty , w hat al ternati ve ave-nues of therapy are open? One approachw as suggested by the f inding that the glyc-erophosphate cycle w as underacti v e in adi -pose ti ssue f rom obese patients. In experi -mental animals, the acti v i ty of these en-zymes are control l ed in part by the level ofthyroid hormones (25). This observation hasled us to reevaluate the ef fects of thy roidhormones in obese subjects (26). E ight obesepatients w ere f ed a high calor ie diet f ol -l owed by calor ie restri cti on (Fig. 5). D uringthe period of restr i cted intake these subjectsw ere treated w i th tr i i odothyronine. W i ththe reduction in calor ie intake, the acti v i ty

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B e and 0hesy 1147of the enzym es in th e g lyce ro pho sph ate cy -c le dec lined . W hen triio do th y ron in e w asad ded the activ ity o f the m ito ch ond ria l en -zym e in creased to the leve l a t w h ich it hadb een be fo re th e low calo rie in take w ass tar ted . A s th is en zym e is the ra te -lim itin go ne in the g lyce ro pho sph ate cyc le, th e ac tiv -ity o f th e en tire cyc le w ou ld ap pea r to be in -c rea sed by thy ro id ho rm ones. T h is in creasew as accom pan ied by a co rrespon d ing rise into ta l oxy gen co nsum ption . F rom ou r p rev i-o tis d iscu ssion it w ou ld appea r th at the lev e lo f activ ity o f th e g ly cerop hosp ha te cy clem ay be inve rse ly re lated to the e ffic iencyw ith w hich foo dstu ffs a re o x id ized . W henth e ac tiv ity o f the cyc le is inc rea sed , a s itw as during the adm in istra tion o f triio do -th y ron in e, e ffic ien cy is redu ced and m oresubs tra te requ ired to p rod uce th e sam equan tity o f A TP .

I t m u st be em phasized th at the se la st tw ostu d ie s w ith thy ro id horm on e h av e b eenconduc ted und er th e ca re fu lly con tro lledcon d ition s o f a m etabo lic w ard . M oreo ve r,the do ses u sed w ou ld be con side red la rg e bythe usu a l c rite r ia o f w h at is requ ired fo rtrea tm en t o f h ypo thy ro id ism . H ow ev er ,they do sugg est tha t som e the rapeu tic m o-da litie s th at have com e unde r recen t cr iti-c ism m ay need reev alu atio n as po ten tia lag en ts in our sea rch fo r m ore effec tiveway sof d ea ling w ith ob esity .

REFERENCES

1 . U . S . Pu blic H ealth Serv ice. Ob e s i t y a n d He a l t h,p . 1 9 and 2 0 .

2 . M ooiu M . E ., A .STUN KA RD A ND L. SR OLE .O be sity , soc ia l cla ss an d m en ta l illn ess . . Am.M ed. A sso c . 8 1 : 9 6 2 , 1 9 6 2 .

3. K ANNEL , W . B ., J. E . LEBAUER , T . R . DAWBER TAN D P . M . MCNAM ARA . R e la tion of bo dy w eigh tto deve lopm en t of corona ry h eart d isea se . T heFram in gh am Study . Circu la t ion 3 5 : 7 3 4 , 1 9 6 7 .

4. BULLEN , B . A ., R . B . R EEDAN D J. MAYER . P hy s i -ca l ac tiv ity o f ob e se and no nobese ado le sc en tgirls ap pra ised b y m otion p ic tu re sam pling . Am .j. Cl i n . Nut,- . 1 4 : 2 1 1 , 1 9 6 4 .

5. CH nuco, A -M ., AN D A . J. STUNKARD . P hys ic a lactiv ity a nd hum an obe sity . N ew Engi . J. Me d .263 : 93 5 , 19 60 .

6. WILK INS , L ., R . M . BL IZ ZARD A ND C . J. MIGEON .Th e D iagn os is a nd Trea tm en t o f E nd ocr ine D is -o rde rs in C hildho od an d Adolescen ce (3rd ed ).Spring f ie ld , Ill.: Th om as, 196 5 , p . 565 .

7. BRAY , G. A ., M . SC HWARTZ , R . R . R 0zIN AN D J.L IS TER . Som e re la tion sh ip s b e tw een oxyg en con -sum p tion and b ody com pos it ion in ob e se pa -tien ts. In p ress .

8 . KINSELL , L . W ., B . G UN N ING , G . P . M ICHAE L S , J.R I C HARD SON , S. E. C ox A ND C . LEN NON . C a lorie sd o coun t. M e tab . C lin . E xp tl . 13: 195 , 19 64 .

9. MAYER , J. Ove rw eig h t: C a use s, C o st an d Contro l.Eng l ew o o d Cl i f f s , N. J. : Prent ice-Ha l l , 1 9 6 8 , p . 2 .

1 0 . STUNKARD , A. , AN D M . MCLAR EN - HUME . Th e re -su lts o f tre a tm en t for o b es ity . Ar c h . I n t e r n a lMe d . 1 0 3 : 7 9 , 1 9 5 9 .

1 1 . G sv , H. , AN D D. C. KALLENBACH . Ob e s i t y t r e a t -ment: resu lts on 2 1 2 o u t p a t i e nt s . J . Am . D ie te t .A s so c . 1 5 : 239 , 1 939 .

12 . FE L LOWS , H . 1 -I. S tudie s o f rela tive ly n orm a lo bese in(liv i(lu als (luring and a fte r d ieta ry r e-strictions. A n i . J . M ed . Sr i . 1 8 1 : 3 0 1 , 1 9 3 1 .

1 3 . HARVEY , H . I., AN D \V . D . S IMMONS . Weigh t re-duc tion : a s tud y ofh e group m eth od . R epo rt ofprogre ss . Am . J . M ed . S ci. 2 2 7 : 5 2 1 , 1 9 5 4 .

1 4 . MUNVES , E . D . D iete tic in terv iew or group (us-cu ss ion -d ec isio n in reduc ing . I. Am . D iete t . A s-S o c . 2 9 : 1 1 9 7 , 1 9 5 3 .

1 5 . OSSERMAN , K . E ., AN D H . 0. DOLGER . O bes ity ind i ab e t e s : a s t u d y o f t h e r a p y wi t h a n o r e x i ge n i cdrugs . A nn . In te rna l M ed . 3 4 : 7 2 , 1 9 5 1 .

16 . YOUNG , C. M ., N . S . M ooiu K .BER R E S FORD , B . M .E IN SET AND B . G . W ALDNER . The p ro b lem s of theobese pa tien t. I. A m . D iete t. A sso c . 3 1: 11 11 ,1 9 5 5 .

1 7 . GLENNON , J. A . W eig h t r edu c tion -an en igm a .Ar c h . I n t e r n a l Me d . 118 : 1 , 196 6 .

1 8 . HIRS cH , J ., J . L. K N ITrL E A ND L . B . SALANS . Celllip id con ten t a nd cel l num ber in ob ese and non -o b ese h um an ad ipo se tis su e . I. C lin . In ve st. 45 :1 0 2 3 , 1 9 66 .

19 . BRAY , G . A . Th e s ize o f h um an fat cel ls.l i n .R e s . 17: 608 , 1 969 .

20 . BRAY , G . A . E ffe ct o f c alo ric restric t ion on en erg yexp end itu re in ob e se patien ts. Lancet 2 : 3 9 7 ,1968 .

21 . GRAND E , F. , J. T . ANDERSON AN D A . KEY S.Changes of basal m etabo lic ra te in m an in sem i-s ta rva tio n an d re feed in g . J . A pp l. P hy s i o l . 12 :2 3 0 , 1 9 5 8 .2 2 . MAYER , J. , N. B . MARSHAL L , J . J . V ITALE , J. H.CHR ISTENSEN , J. H. MA SHAYAH I A ND F. J. S T A R E .Exe rcise , foo d in take an d body w e igh t in n or-m a l ra ts an d g ene tic ally ob ese adult m ic e.m.I. Physio l . 1 7 7 : 544 , 195 4 .

2 3 . MAYER , J. , P . ROY AN D K . P . M IT RA . Relat ion

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8/2/2019 Am J Clin Nutr-1970-BRAY-1141-8 (Myth of Diet in the Management of Obesity)

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b etw een ca lo ric in take , bod y w e igh t, andhysi-ca l w ork in an ind ustr ia l m ale po pu la tion inWe s t Benga l . Am. I. Clin. Nutr. 4: 1 69 , 195 6 .

24 . GALTON , D . J. , A ND G. A . B R A Y . M etabo lism ofa -g ly cero l pho sph ate in uman ad ipose t issue inobes i ty . J. Clin. Endocrino l. Metab. 2 7 : 1 5 7 3 ,1967 .

25 . Lsam , Y-P. , A ND H . A . LARDY . In flu en ce of th y ro id

horm ones on L -a-glyceroph osphate dehydrogen-ases and o th er dehyd r ogenases in var ious organsof the ra t. I . Bio l. Chem. 240: 1427 , 1965 .

26 . B R A Y , G . A . E ffe ct o f d iet and tri iod o th yro n in eon the a ctiv ity o f sn-g lyc ero l-3 -ph osp hate dehy-drogena se an d on the m etab o lism of g lucose andp y r u v a t e b y ad ipose tissu e o f o bese pa tien ts . I .Cl i n . I nv e s t . 48: 14 13 , 19 69 .

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