Response

high fat
H. Kasper,

of body weight
to a low carbohydrate,
diet in normal
and obese subjects
H.

Thiel

and

M.

Ehi

conditions
with a low carbohydrate,
high fat formula
and a low calorie
reducing
diet with
the
customary
carbohydrate-fat
ratio,
respectively.
The
contents
of the formula
diet per 100 g dry powder
(Brauns
Oral) was 56 g carbohydrate,
13 g fat,
21.4
g protein,
and
supplemental
vitamins
and
minerals
to meet the daily requirements.
The following
fats were added to the diet at differing
doses:
corn oil, olive oil, safflower
oil, and butter.
Water
was allowed
ad libitum
in the form
of coffee,
tea,
and mineral
water.
The composition
of the various
diets is listed in Table 1.
The carbohydrate-fat
ratio and total calories
of
diets 1 and 2 are in agreement
with the customary

reducing
regimens
in terms of conventional
foods.
Diets 3 and 5 are low in carbohydrate
and relatively high in fat content.
With regard
to total
calories,
diet 4 corresponds
with diet 3; 410 kcal
in the form of fat were substituted
isocalorically
for glucose.
Besides
the daily control
of the body
weight,
tests
performed
before
and
during
the
dietary
experiment
included
the determination
of cholesterol,
triglycerides,
urea,
uric acid,
total
protein,
serum
glutamate-oxaloacetate
and
glutamatepyruvate
transaminase,
and also the semiquantitative analysis
of urinary
acetone.

Results
Experimental

procedure
on

Studies
Studies

on

normal-weight

volunteers

Five
volunteers,
three
males
and two females
aged 17 to 26 years,
were given a formula
diet for
a maximum
period
of 45 days. The composition
of
the diet was as follows:
168 g carbohydrate,
64 g
protein,
and 39 g fat with a supplement of vitamins
and minerals
to meet
requirements.
Water
in the
form
of tea, coffee,
and mineral
water
was permitted
ad libitum.
The
formula
diet was supplemented
at 5-day intervals
in increasing
amounts
of
fat, which
was given as corn oil or olive oil. These
fats differ
by their
content
of linoleic
acid;
corn
oil containing
approximately
45%
and
olive
oil
approximately
7%
of linoleic
acid.
Throughout
the experimental
period,
we performed
daily determinations
of fecal
fat excretions
(by the method
of van de Kamer
et al. (8)) and of the body weight.
Studies

on

obese

normal-weight

volunteers

Under
the selected
experimental
conditions,
healthy
individuals
receiving
a constant
daily
amount
of carbohydrate
(690
kcal)
and protein
(276
fat calories)
are capable
of taking
orally
an amount
of more
than 600 g fat-day.
Up to that dose
the utilization
of fat is essentially
normal.
The absorption
coefficient
varies
between
94 and
98, decreasing
temporarily
to values
below
90 in a number
of the subjects
(for details
of
fat utilization
under
high oral intake,
see (9)).
At daily
intakes
of 300
to 400
g fat and
higher,
the test subjects
reported
a marked
sensation
of heat
extending
over
the entire

subjects

A total of 25 obese subjects

ranging
tween
20 and 54 years were treated
under

in age bein-patient

Medical
University
Klinik,
8700
Luitpoldkrankenhaus,
West Germany.
I

Wurzburg,

197
The

American

Journal

of Clinical

Nutrition

26: FEBRUARY

1973,

pp.

197-204.

Printed

in U.S.A.

Downloaded from www.ajcn.org by on July 5, 2009

The mechanisms
that underline
the regulation
of body
weight
are largely
unknown.
As early
as the turn
of the century,
it had
been pointed
out by Klemperer
(1), Neumann
(2),
Grafe
and
Graham
(3),
and
Epstein
(4) that these
regulating
mechanisms
do not
involve
a balance
problem
per se, i.e., that
caloric
intake
in excess
of normal
requirements
invariably
will give rise to an increase
in body
weight
due to fat storage.
The demonstrable
imbalance
between
the
caloric
intake
and the increase
in body weight
is explained
by the so-called
luxus
consumption,
which
is an increase
in thermogenesis
detectable,
according
to more recent
findings,
on physical
exercise
rather
than
under
resting conditions
(3, 5-7).
The present
study
has been undertaken
to
investigate
the significance
of nutrient
interrelations,
with
particular
emphasis
being
placed
on the nutritional
carbohydrate-fat
relationship,
insofar
as it is involved
in the
regulation
of body weight
in man.

198

KASPER

body
and a marked
tendency
toward
sweating, irrespective
of the type of fat administered.
A different
response
of the body
weight
was obtained
when
using
olive
oil and corn
oil. In two of the subjects
(for comparison,
see cases 6 and 7 in Fig. 1) who had ingested
increasing
amounts
of olive oil during
an exTABLE

ET

AL.

perimental
period
of more than 40 days (thus
increasing
the total
calories
from
3,178
to
8,878), a weight gain of approximately
9 kg
was observed.
As a function
of food intake,
the course
of the weight
curve
of one of the
two subjects
is shown
in detail
in Fig.
2. If
fat was given in the form of corn oil, the response
of the body weight
was different
from

Composition

of diets used in treatment

no.

Protein

Carbohydrates

Fat
Diet

of obesity

Caloric
ratio
carbohydrate-fat

Total calories
g/day

855
1006

1707
1707

2150

242
186
1385
975
1507

g/day

112
100
56
156
112

kcal/day

459
410
230
640
459

g/day

43

184
410

1:0.5

21

92

21
43

92
184

1:6.0
1:1.5
1:3.3

100

I rCI)aratlofl

kcal/day

Formula
diet
Diet kitchen
Formula
diet
Formula
diet
Formula
diet

1:0.45

total
calories

intake

per day

fat

5000

3000

(1)

(2)

40
FIG.

1. Response

hydrate
and
olive oil.

protein

of body
content.

weight
Subjects

50

in normal
subjects
under increasing
oral intake
of fat at constant
carbo1-5 received
fat in the form of corn oil, subjects
6 and 7 in the form of

Downloaded from www.ajcn.org by on July 5, 2009

26
20
149
103
162

kcal/day

RESPONSE

#{149}

IV

2213

calories

[j

3177

3138

.8

OF

BODY

4063

4102.8

5027 . 8

bodyweight
(kg)

kg

1+0.1

kg

/ day

kg

6877.8687J

+0.26 kg+0.74

kg, .0.2 kg

/daY;/daYj/d$Y

+ 0.15

kg/day

/d*y

10

40

20

days
FIG.

Response

2.

oil at constant

that

of body

carbohydrate

weight
and

in a normal

protein

subject

increasing

oral

intake

of fat in the form

of olive

content.

olive oil was consumed,

as can be
the weight
curves
1 to 5 in Fig. 1.
Despite
an excessively
high caloric
intake,
the
body
weight
invariably
fell below
the initial
level at largely
normal
utilization
of the dietary fat. Subject
2 was the only one to exhibit
a slight
increase
in body
weight
when
the total caloric
intake
was more
than 6,000
seen

under

when
from

1caies

[1 Jries

1750.5

2675.5

2715.3

3640.3

-0.3

-0.1

3138.0

3600.5

_______

4063.0

4988.0

___________

4102.8

4565.3

#{149}
0kg

+0.05kg/day

5027.8

5952.8

4.0
5952.8

body weight
(kg)

85

83

kcal/day

during

Figure
body
loric
and
the

the

last

experimental

3 illustrates
in detail
weight
in relation
fat intake.

the
to

period.

response
the

total

of
ca81

kg

/day

Studies

in obese

Obese
subjects
were
treated
tient conditions
with the diets
1. The response
of the body
in Table

2.

Compared

w.O.lkgylkg

/day

/dly

subjects
5

seen

kg

/day

under
in-palisted
in Table
weight
can be
with
the weight

10

15 doys

- - 25

30

35

FIG. 3. Response
of body
weight
in a normal
subject under increasing oral intake of fat in the
form of corn oil at constant
carbohydrate
and protein content.

Downloaded from www.ajcn.org by on July 5, 2009

-0.2

5913

#{149}:

6415 3J6877.8

5952 . 8

/day

5913

5913

5450 5

48

fat
total
calories

I,I..

199

WEIGHT

200

KASPER

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Downloaded from www.ajcn.org by on July 5, 2009

RESPONSE

OF

diet No.3

body weight

115

diet

+o.4

diet

No.3

,
I

kg)

diet

No.4
I
I

170

owl

95

: o.o#{128}
kg/day

kg/day

4.

-0.51 kg/day,+ 0 kg/daY.

10

FIG.

we

Response
of body weight
in a 28-yearunder
diets 3 and 4. Fat was given
of corn oil.

male subject
the form
ditt Na t
weight
kg

120
body

diet i.5

(Cl

diIt N05 (0)

diet No 5 (C(

110

110

100

100

03(Igdae

.030hgda,
70

:ew
00

Cay,

FIG.

male

cluded

5. Response
of body
subject
under
diets

intake

weight
1 and

in a 37-year5. Diet 5 in-

of corn oil (C) and olive oil (0).

body

weight

(kg I

det

11

FIG.

old male

0.20

No

kg/day

26;

30
days

41

St

6. Response
of body weight in a 22-yearsubject under diet 3 (intake of corn oil).

FIG.
7. Serum
cholesterol
obese
subjects
receiving
normal
starting
therapy
and under
low
high fat reducing
diets
(D).

concentration
food
(N)
carbohydrate

in
before
and

the body weight.

In contrast
to case 23, a
maximal
weight
loss was achieved
in cases
1,
2, and
1 5 when they were taking
fats high in
linoleic
acid. Because
in the majority
of the
obese
individuals
diets with a varying
carbohydrate-fat
ratio
were
applied
during
the
course
of treatment,
Figs. 4 to 6 show the behavior
of the body weight
in several
patients
under
various
diet regimens.
Whereas
a distinct weight
reduction
was obtained
in the 23
obese
patients
listed
in Table
2 while
they
were consuming
a low carbohydrate,
high fat
diet, attempts
at lowering
the body weight
in
two
obese
subjects
with
diabetes
mellitus
were not successful,
in spite of an ample
experimental
period.
Figure
7 shows
the serum
cholesterol
concentrations
determined
when
initiating
the
treatment,
as well as during
and after
termination
of the dietetic
therapy.
Values,
which
at the beginning
of the test period
had been
highly
elevated
above
normal,
revealed
a
tendency
to become
normal
both
with
diets
of

100

201

WEIGHT

Downloaded from www.ajcn.org by on July 5, 2009

loss under
diet 2 (1 ,006 kcal), which
was prepared
in our diet kitchen
using
conventional
foods,
the relatively
large
mean
weight
loss
per
day with
diet
1 (an 855-kcal
formula
diet)
has to be attributed
in part to the relatively low salt content
of this diet. Diets 3 and
5 (1,707
and/or
2,150-kcal
formula
diets
with a moderate
carbohydrate
and a high fat
content)
produce
a mean
daily
weight
loss
of 0.30 kg. Despite
a higher
total caloric
intake, the weight-reducing
effect clearly
equals
that
of a standard
clinical
reducing
diet of
1 ,000 kcal. The decisive
influence
of the nutritional
carbohydrate-fat
ratio on the regulation of the body weight
is reflected
by the response
of the body weight
with diet 4, which
causes
a mean
daily weight
reduction
of 0.05
kg. At an identical
total caloric
intake
fat was
substituted
for
glucose
by isocaloric
exchange.
The small
number
of cases
investigated
do not provide
unequivocal
information as to whether,
as in the high-dosed
fat
intake
in normal-weight
subjects,
the linoleic
acid content
of the fat influences
the behavior

BODY

202

KASPER

Discussion
Five normal
volunteers
ingested
increasing
doses of fat in the form of a formula
diet for
a maximum
of 45 days,
with carbohydrate
and protein
intake
remaining
constant.
Contrary
to common
belief,
normal
subjects
are
apt to digest
and absorb
more
than
600 g
TABLE

3
Response
of serum
triglycerides
the normal
range
in the obese
of Table
2
Serum

elevated
subjects

triglyceride
mg/100

Patient

above

concentration,
ml

no.
Before

dietary

After

treatment

7
8
11

17

20
21
U

drate,

Before
high

and
fat

after
diets.

treatment

dietary

treatment

410
530
260
360
295
390

200

220
220
180
180
160
with

low

carbohy-

AL.

fat/day
(9).
When
the
daily
fat
intake
reached
levels
of 300 to 400 g, all subjects
reported
a strong
and persistent
sensation
of
heat.
It was
striking
to observe
that
the
weight
gain did not correlate
with the caloric
intake.
Particularly
if fat was given
in the
form
of corn
oil, a distinct
discrepancy
between
the caloric
intake
and the response
of
the body
weight
was detectable
(Figs.
1 and
3). This phenomenon
was less conspicuous
if
fat was taken
in the form
of olive oil (Figs.
1 and 2). The two fats differ
particularly
by
their linoleic
acid content,
which
is approximately
45 % and 7 % for corn oil and olive
oil, respectively.
On the basis
of the experimental
results
obtained,
it appears
probable
that under
a relatively
low carbohydrate
and
protein
intake,
increasing
amounts
of fat produce
an increase
in the metabolic
rate that
becomes
particularly
marked
if fats high in
linoleic
acid
are given.
This
results
in a
weight
gain not correlated
with
the caloric
intake,
and furthermore,
in a marked
sensation of heat
and a pronounced
tendency
to
sweating
experienced
by all subjects.
Based
on these
experimental
results,
obese
individuals were treated
with low carbohydrate,
relatively
high fat formula
diets (Table
1). The
response
of the body
weight
was
compared
with the weight
loss obtained
under
one of
the conventional
low fat, relatively
high carbohydrate
diets.
Under
the low fat reducing
diets,
the results
in a total of 23 obese
mdividuals
(Table
2) indicate
that the average
daily weight
loss is 0.49 kg when a 855-kcal
diet (diet 1) is consumed
and 0.26 kg with a
1 ,006-kcal
diet (diet 2). By comparison,
the
average
daily weight
loss under
high fat, low
carbohydrate
diets
was 0.30
kg/day
under
diet 3 (1,707
kcal),
and 0.32
kg/day
under
diet 5 (2,150
kcal),
notwithstanding
the essentially
higher
total
calorie
intake
per day.
If fat was exchanged
isocalorically
for glucose
(diet 4), the weight
loss ceased
(for comparison, see Table
2, Fig. 4).
In light
of these
results,
it would
appear
justified
to conclude
that under
a low carbohydrate,
high fat diet regimen,
an increased
energy
output
takes
place,
which
is emitted
in the form of heat. The small number
of experiments
conducted,
in which
we compared
butter,
olive
oil, corn
oil, and safflower
oil,
are not adequate
to deduce
reliably
whether.

Downloaded from www.ajcn.org by on July 5, 2009

1 and 2 (low fat content)

and diet 5 (162
g
fat/day).
Cholesterol
concentrations
also did
not rise during
the stages
of treatment
involving administration
of olive
oil. After
being
discharged,
both the body
weight
and serum
cholesterol
concentrations
of patients
who
had been maintained
for months
on a diet of
50 to 60 g carbohydrate
and 140 to 160 g fat
continued
to normalize.
Preference
was given
to fats high
in linoleic
acids
while
protein
intake
was unrestricted.
In subjects
exhibiting
normal
serum
triglyceride
concentrations
at
the outset
of the experiments,
the triglyceride
levels varied
within
the normal
range
during
the course
of study.
Elevated
initial values
invariably
revealed
a tendency
to normalize
(for comparison,
see Table
3).
During
the dietary
treatment,
urea,
uric
acid,
total
protein,
glutamate-oxaloacetate
and
glutamate-pyruvate
transaminase
remained
unchanged.
Traces
of acetone
were
detected
in the urine
only sporadically.
The general
condition
of the obese
subjects
during
the experiment
was satisfactory;
there
were
no gastrointestinal
complaints,
and the amount
of fat excreted
in the feces
was within
the normal
range.

ET

RESPONSE

OF

oil (but with constant

carbohydrate
and protein intake)
was raised
continuously
up to a
daily
ingestion
of more
than
6,800
fat calones.
Under
normal
utilization
of fat in the
gastrointestinal
tract,
it was seen
that there
was only a slight weight
gain, compared
with
the caloric
intake.
This
effect
was particularly
conspicuous
with
corn
oil and less so
with olive
oil. The
two oils differ
by their
linoleic
acid content.
Based
on these
results,
we treated
obese
subjects
with high fat, low
carbohydrate
diets.
If the carbohydrate
content of the diet was not more
than
50 to 60
g/day
and the fat content
approximately
150
g/day,
an average
daily weight
reduction
of
0.3 kg was
achieved.
The
cholesterol
and
triglyceride
concentrations
in the
serum,
which
had been raised
at the beginning
of the
experiment,
invariably
showed
a tendency
towards
normalization
under
this
dietary
program.[
References
1.

KLEMPERER,

G. Untersuchungen
wechsel
und
Ern#{228}hrung in
Kim. Med.
16: 550, 1889.

2.

NEUMANN,

Lehre

R. 0.
von

dem

Menschen

unter

der notwendigen

content
oil and

of a
olive

StoffZ.

1, 1902.
3.

E.,

GRAFE,

D.

AND

sungsf#{228}higkeit
Oberreichliche
C/iepn. 73:
4.

Uber
die AnpasOrganismus
an
Z.
P/zysiol.

GRAHAM.

des tierischen
Nahrungszufuhr.

1, 1911.

W. Die Fettleibigkeit

EPSTEIN,

(Corpulenz)
und
nach physiologischen
GrundBergmann
Verlag,
1883.
K. Zum Energiehaushalt
des menOrganismus.
Kim.
Woc/zsc/ir.
8 1:

ihre Behandlung
s#{228}tzen.Wiesbaden:
5.

IRSIGLER,

schlichen
845, 1969.
6.

MILLER,
D. S.,
An experimental

high-protein
1967.
7.

MILLER,

AND

diets.

D. S.,

AND

P.
study

MUMFORD.

Am.

I. Cliii.

P.

8.

VAN

DE

BOKKEL,

for

the

C/oem.

9.

KASPER,

KAMER,
AND

H.

H. Faecal

GORDON,

A new

E. S., M.
concept

H.

HUININK,

Rapid
in feces.

fat exeretion,

AND

dosed

G. J.

TEN

method
J. Biol.

diarrhea,

with
highly
3: 321, 1970.
GOLDBERG

20:

Gluttony.
2.
Am. J. Clin.

man.

of fat

1.
or
1212,

low-

Nuir.

MUMFORD.

J. H., H.
A. WEYERS.

determination
177: 347, 1949.

Gluttony.

of overeating

Thermogenesis
in over-eating
Nuir.
20: 1223, 1967.

10.
subjects,
the fat
in the form of corn

bber
Krankheiten.

Experimentelle
Beitr#{228}ge zur
t#{228}glichen Nahrungsbedarf
des
besonderer
Berucksichtigung
Eiweissmenge.
Arc/i.
Hyg. 45:

subjective
complaints
fat intake. Digestion

Summary
In normal
formula
diet

203

WEIGHT

and
oral
CHOSY.

in the treatment
of obesity.
I.
Am. Med.
Assoc.
186: 156, 1963.
11. KNOcK,
B., AND H. U. GREBE.
Di#{228}tetische

Downloaded from www.ajcn.org by on July 5, 2009

as in the experiments
in normal-weight
subjects
receiving
unphysiologically
high
levels
of fat, a different
response
of the body weight
occurs
in obese
subjects
receiving
fats of different
linoleic
acid content.
When
carbohydrate
restriction
was
continued
after
discharge
from
the hospital,
caloric
requirements
being
largely
covered
by fat and proteins,
the body
weight
continued
to normalize, despite
a total caloric
intake
of 2,000
to
2,300/day.
The
serum
cholesterol
concentration
was found
to decrease
in all obese
subjects
(Fig. 7). Triglyceride
concentrations,
which
had been elevated
before
initiating
the
diet, invariably
decreased,
some of them even
falling
to the normal
range
(Table
3).
In summary,
we can state
that under
the
selected
carbohydrate-fat
ratio,
the
body
weight
of obese
individuals
was reduced,
despite
a relatively
high caloric
dietary
intake
of adequate
nutritious
value.
The
diet was
well tolerated.
Under
this dietetic
regimen,
serum
cholesterol
and triglyceride
concentrations
were
lowered
(see Fig. 7 and Table
3).
As early
as 1872
and 1883,
respectively,
Harvey
in Great
Britain
and Epstein
(4) in
Germany
drew
attention
to the favorable
weight-reducing
effect
of a ketogenic
diet.
More
recently
several
other
authors
(10-14)
reported
on the beneficial
results
of a low
carbohydrate,
high fat diet in obese
subjects.
They
suggested
restricting
the total
caloric
intake
to approximately
1 ,000 kcal/day.
Because
of the low satiety
value,
it is impossible
to conduct
the diet over
a prolonged
period
and to obtain
a lasting
weight
reduction.
Not
all authors
confirmed
the positive
effect
of
carbohydrate
restriction
in obese
individuals
(1 5-1 7). The objection
that the weight
loss
obtained
under
the low carbohydrate,
high
fat diet was due only to increased
dehydration (1 8) can be disregarded
in view of the
prolonged
experimental
period
of up to 45
days
and the extent
of the weight
loss obtamed.
The
metabolic
processes
that
might
shed some
light on the described
response
of
the body
weight
in normal-weight
and obese
individuals
are as yet unknown.

BODY

204

RASPER

Kohlenhydratrestriktion
Fettsuch
und der

6: 233,
12.

KEKWICK,

study
high
Clin.
13.

1965.
A.,

AND

in der Behandlung
der
Fettleber.
Med. Ernahrung

G. L. S.

PAwAN.

Metabolic
diets

in human
obesity
with isocaloric
in fat, protein
or carbohydrate.
Exptl.
6: 447, 1957.

PENNINGTON,

A. W. Treatment

calorically
unrestricted
343, 1953.

of obesity
I. Clin.

Nuir.

with
1:

R. L. MAIrnN
AND
R. H.
in body composition
during
weight
reduction
in obesity.
Ann.
internal
Med. 63: 604, 1965.
15. PILKINGTON,
T. R. E., H. GAINSBOROUGH,
V.
14.

BENOIT,

WATTEN.

F. L.,
Changes

diets.

Metab.

ET

AL.

M.

Diet and weight

1: 856, 1960.
16. SCHMIDT,
H., J. JANox AND K. D. V0IGT.
Auswirkungen
einer
ketogenen
Kost
auf das
K#{246}rpergewicht, den Intermedi#{228}r- und Elektrolytstoffwechsel
von
Adip#{246}sen. Deut.
Med.
Wochschr.
94: 78, 1969.
17. WESSELS,
M., F. A. GRIES, K. IRMSCHER,
H.
LIEBERMEISTER,
H. BUCHENAU
AND
J. VIEHwEGER.
Metabolische
Konsequenzen
einer
ROSENOER

reduction

AND

M.

in the obese.

kohlenhydratarmen

CAREY.

Lancet

Di#{228}tbei

Deut.

Med. Wochschr.
95: 382,
18. BORTZ,
W. M., A. WROLDSON,
B. ISsEKUTz. Fat, carbohydrate,
loss. Am.

I. Clin.

Nutr.

20:

Normalpersonen.
1970.

1104,

P. Moiuus AND
salt and weight
1967.

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