Efficacy and Safety of a High Protein, Low Carbohydrate Diet for Weight Loss in Severely Obese Adolescents

doi:10.1016/j.jpeds.2010.02.010

The Journal of Pediatrics

Volume 157, Issue 2, August 2010, Pages 252-258

https://doi.org/10.1016/j.jpeds.2010.02.010 Get rights and content

Objective

To evaluate the efficacy and safety of a carbohydrate restricted versus a low fat diet on weight loss, metabolic markers, body composition, and cardiac function tests in severely obese adolescents.

Study design

Subjects were randomly assigned to 1 of 2 diets: a high protein, low carbohydrate (20 g/d) diet (high protein, low carbohydrate, HPLC) or low fat (30% of calories) regimen for 13 weeks; close monitoring was maintained to evaluate safety. After the intervention, no clinical contact was made until follow-up measurements were obtained at 24 and 36 weeks from baseline. The primary outcome was change in body mass index Z-score for age and sex (BMI-Z) at 13, 24, and 36 weeks.

Results

Forty-six subjects (24 HPLC, 22 in low fat) initiated and 33 subjects completed the intervention; follow-up data were available on approximately half of the subjects. Significant reduction in (BMI-Z) was achieved in both groups during intervention and was significantly greater for the HPLC group (P = .03). Both groups maintained significant BMI-Z reduction at follow-up; changes were not significantly different between groups. Loss of lean body mass was not spared in the HPLC group. No serious adverse effects were observed related to metabolic profiles, cardiac function, or subjective complaints.

Conclusions

The HPLC diet is a safe and effective option for medically supervised weight loss in severely obese adolescents.

Section snippets

Methods

We used a 12-week, randomized controlled study design that compared the impact of the HPLC diet versus a LF diet in producing weight loss in severely obese adolescents. Both groups were informally prescribed an exercise program that included at least 30 minutes of daily moderately vigorous physical activity. Subjects were admitted to the Pediatric Clinical Research Center (CRC) for baseline testing and initiation of the diet, followed at 2-week intervals in the outpatient CRC clinic, and

Results

A total of 51 subjects were consented and randomly assigned for the study. The majority of the subjects were Caucasian (26, 56%); 10 (22 %) were African American; 6 (13%) were Hispanic; and 4 (9%) were Asian. Five subjects (3 HPLC and 2 LF) dropped out before or during the initial in-patient stay; baseline data from these subjects were not included because they did not initiate the intervention. An additional 13 subjects (6 from HPLC, and 7 from LF groups) dropped out during the course of the

Discussion

We report a large, randomized intervention trial in severely obese adolescents, which compared the efficacy and safety of a high protein, low carbohydrate diet versus a low fat hypocaloric diet for weight loss. As has been seen in one other study in adolescents⁵ and several studies in adults,16, 17, 18, 19, 20 we found a significantly greater short term decrease in BMI-Z and in weight loss with the HPLC diet. This study in adolescents included 6-month follow-up measurements for the 2 dietary

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School-age children (6–10 years) diagnosed Ov or Ob were randomized to receive three different dietary interventions for two months: standard diet (SD), high protein (HP) diet, and HP diet with calcium caseinate (HPC); BMI (Z-score and percentiles), body composition, indirect calorimetry (REE^IC), energy intake (24-h recall questionnaire) and satiety (visual analog scale) were evaluated before and two-months after intervention.
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More recently, low carbohydrate approaches have shown promising weight loss results, including a case series using a slightly more liberalized version of the PSMF diet in inpatient and outpatient settings [15,16]. Despite this promising evidence, the PSMF diet is not a treatment option regularly offered in pediatric tertiary care weight management clinics [14,15,17–20]. The purpose of this paper is to describe the rationale and design of a pilot study to evaluate the acceptability and effectiveness of a revised protein sparing modified fast (rPSMF) implemented as a weight loss treatment option for children and adolescents with severe obesity.
Aggressive dietary interventions may provide an accessible treatment option for children and adolescents with severe obesity who are not successful with traditional lifestyle behavioral interventions or do not want or qualify for weight loss surgery. One such intensive dietary option is the protein sparing modified fast (PSMF). The PSMF involves minimal carbohydrate intake to induce ketosis, while maintaining adequate or high protein intake to minimize catabolism. The PSMF, under medical supervision, can be an effective and safe intervention for children and adolescents, yet the PSMF diet is not regularly used in the treatment of pediatric severe obesity. This paper describes the rationale and design for a pilot study to evaluate the acceptability and effectiveness of a revised PSMF (rPSMF) implemented as a weight loss treatment option for children and adolescents with severe obesity in a pediatric tertiary care weight management clinic. The primary aim of the study is to evaluate the acceptability of the rPSMF as assessed by adherence, satisfaction with the intervention, and participation rate using quantitative and qualitative methods. The secondary aim is to investigate the effectiveness of the rPSMF on improving a) anthropometric measures (weight, body mass index [BMI], BMI z-score); b) metabolic measures (lipid profile, glycosylated hemoglobin, liver function tests); and c) quality of life. Results of this study will provide guidance for the standardization of a pediatric rPSMF protocol in a clinic setting, delineate which factors improve or hinder adherence and weight loss and provide preliminary data for a multicenter randomized controlled trial.
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Multicomponent approaches included modules delivered by nutrition, behavior, physical activity, and medical specialists.39,42,48,51,54-88 Nutrition-focused interventions employed various diet manipulations along with eating behavior modification.89-96 Behavioral interventions included stress management, parent education, stimulus control, guided imagery, therapy aimed at increasing self-efficacy and self-esteem, and nutrition education.97-106
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: Supported by the Pediatric Clinical Translational Research Center (RR00069), NIH (K24-RR018357-01, T32 DK07658), and the National Cattlemen's Beef Association. The authors declare no conflicts of interest.

: No reprints are available from the author.

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Original ArticleEfficacy and Safety of a High Protein, Low Carbohydrate Diet for Weight Loss in Severely Obese Adolescents

Objective

Study design

Results

Conclusions

Section snippets

Methods

Results

Discussion

J Pediatr

J Pediatr Nurs

J Pediatr

J Nutr

Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report

Pediatrics

High body mass index for age among US children and adolescents, 2003-2006

JAMA

Preventing Childhood Obesity: Health in the Balance

Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study

J Pediatr

The effects of a high-protein, low-fat, ketogenic diet on adolescents with morbid obesity: body composition, blood chemistries, and sleep abnormalities

Pediatrics

Feasibility of a clinic-based hypocaloric dietary intervention implemented in a school setting for obese children

Obes Res

Recommendations for treatment of child and adolescent overweight and obesity

Pediatrics

Measuring effectiveness of dietetic interventions in child obesity: a systematic review of randomized trials

Arch Pediatr Adolesc Med

Efficacy and safety of low-carbohydrate diets: a systematic review

JAMA

Dietary protein and weight reduction: a statement for healthcare professionals from the Nutrition Committee of the Council on Nutrition, Physical Activity, and Metabolism of the American Heart Association

Circulation

A Biometric Study of Basal Metabolism in Man

Reproducibility, power and validity of visual analogue scales in assessment of appetite sensations in single test meal studies

Int J Obes Relat Metab Disord

Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man

Diabetologia

Original Article
Efficacy and Safety of a High Protein, Low Carbohydrate Diet for Weight Loss in Severely Obese Adolescents