1. www.csiro.au High Protein Low Carbohydrate Diets: Targeting Who Benefits Dr Manny Noakes Senior Research Dietitian CSIRO Human Nutrition (Clinical Research Unit)

2. Diabetes risk increases with obesity and will more than double, from 140 million to 300 million in the next 25 years. Diabetes leads to serious complications such as heart, eye and kidney disease and a shortened life span. Costs of obesity to community > $6b/y Obesity Epidemic

3. Other terms that are used that generally refer to the same syndrome include: Syndrome X Metabolic Syndrome Insulin Resistance Syndrome Deadly Quartet Syndromic Obesity

4. Constellation of major risk factors, life-habit risk factors and emerging risk factors Over-represented among populations with heart disease Clue is distinctive body-type with increased abdominal circumference (although some leaner men and women can have metabolic syndrome) Metabolic Syndrome

5. ATP III Guidelines Glucose Abdominal Obesity HDL-C BP TG Glucose 6.1mmol/L Waist Circumference 102cm 88cm HDL-C 1.0 mmol/L 1.3 mmol/L BP 130/ 85 mmHg Triglycerides 1.7mmol/L Diagnosis is made when 3 or more of these risk criteria are met Diagnostic Criteria for Metabolic Syndrome

6. Inactivity Aging Atherosclerosis Genetics Obesity PCOS Dyslipidemia Hypertension Type 2 diabetes NASH Genetics Insulin Resistance: Causes and Associated Conditions INSULIN RESISTANCE

7. * Total area under 3-hour response curve (mean of 2 tests). Olefsky JM et al. Am J Med. 1974;57:551-560. 625 500 400 300 200 100 200300400500600 Insulin Response to Oral Glucose* Plasma TG (mg/dL) r = 0.73 P < 0.0001 Insulin Resistance and Hypertriglyceridemia

8. Ford ES, et al JAMA 2002 45 35 0 8814 aged 20 years or older from NHANES III (1988-1994) The age-adjusted prevalence : men (24.0%) women (23.4%) Prevalence of Metabolic Syndrome

9. Marketing Weight Loss

10. Skov et al 1999 High-carbohydrate (HC, protein 12% energy) n=25 High-protein (HP, protein 25% energy) n=25 Results After 6 Months 5.1 kg in the HC group 8.9 kg in the HP group (P < 0.001) More subjects lost > 10 kg in the HP group (35% vs 9%). HP diet decreased fasting plasma triglycerides significantly. Protein Versus Carbohydrate in ad libitum Fat Reduced Diet

11. Greater weight and fat loss (Skov et al,1999) Obese subjects Increased satiety (Latner & Schwartz, 1999) Glucose tolerant women Thermic effects (Hwalla Baba et al,1999) Obese, hyperinsulinaemic men Lean body mass spared (Piatti et al,1994) Glucose tolerant women High protein/Low GI (Dumesnil et al) 25% decrease in ad libitum intake Obese men Increased Protein / Carbohydrate Ratio

12. Insulin sensitivity (Clifton et al,1998) Subjects with IGT Greater abdominal fat mass loss (Parker et al 2002) Type 2 diabetes Greater lowering of LDL-C (Parker et al 2002) Type 2 diabetes Thermic effect of HP meal 28% greater (Luscombe et al 2002) No change in REE Type 2 diabetes Greater lowering of TG (Farnsworth et al (in press)) Subjects with elevated insulin Lean body mass spared (Farnsworth et al (in press)) Subjects with elevated insulin Increase Protein / Carbohydrate Ration: CSIRO Studies

13. Renal Function Urinary albumin excretion was not affected by dietary protein during weight loss: N=19 with microalbuminuria. HP diet: 24.2 to 19.8 mg/l (n=12) LP diet: 4.3 to 3.5 mg/l (n=7)

14. Aim To compare a high protein weight loss diet with a high carbohydrate diet in women participating in a 12 week intervention (and subsequent follow up for 1 year) on the following outcomes: Weight loss and body composition Nutrient status Bone turnover markers Measures of heart disease risk. Diets: High carbohydrate High protein, high red meat

15. High Meat Protein (5600 KJ) Cereal Low fat milk (250ml) Wholemeal bread (2 slices) Fruit (2) Beef / lamb 200g - dinner Chicken/fish/meat 100g - lunch Vegetables 2.5 cups Diet Yoghurt 200g Canola oil 3 tsp Wine 2 glasses/week (optional) 34% protein 20% fat 46% carbohydrate 109g protein 31g fat 161g carbohydrate

16. Cereal SKIM milk (250ml) Wholemeal bread (3 slices) Fruit (3) Chicken / pork / fish 80g Vegetables 2.5 cups Canola oil 3 tsp Pasta/rice 120g cooked Low fat biscuits 3 Wine 2 glasses/week (optional) High Carbohydrate (5600 KJ) 17% protein 20% fat 64% carbohydrate 57g protein 31g fat 229g carbohydrate

17. Overall Results DietAverage Weight Loss Min Weight Loss Max Weight Loss NDropouts High Protein7.6kg0.55kg18.2kg515 High Carbohydrate6.9kg0.15kg14.5kg4916

18. Weight Loss by Triglyceride Status * Sig Diet Effect High Protein High Carb

19. Arm Fat Leg Fat Abdominal Fat DEXA

20. Total And Midriff Fat Loss - DEXA Data * Sig Diet Effect High Protein High Carb

21. LDL Cholesterol 4.8% High Protein High Carb

22. Triglycerides 4% 13% High Protein High Carb

23. Triglycerides by TG status HIGH TG LOW TG 10% 28% High Protein High Carb

24. High Protein High Carb P=0.036 26% 9% Triglyceride Change By Insulin Status Change in TG Insulin Split Low Insulin High Insulin

25. Calcium excretion mmol/24hr High Protein High Carb Week 0 Week 12 Reference Range: 2.5-7.5mmol/24hr Calcium Excretion Calcium excretion decreased on both diets

26. Protein versus Carbohydrate and Markers of Bone Turnover Deoxypyridinoline/creatinine ratio Pyridinolone /creatinine ratio High Protein High Carb High Protein High Carb Both weight loss strategies associated with increased bone turnover. No effect of diet composition. Week 0 Week 12

27. Haemoglobin High Protein High Carb Reference Range: 115-165g/L * No change Mean Week 0 Week 12

28. Vitamin B12 High Protein High Carb Reference Range: 140-700pmol/L 12% increase 13% decrease Week 0 Week 12

29. Conclusion #1 Moderately High protein high red meat diets and conventional high carbohydrate weight loss diets provide health benefits. Plasma triglycerides lowered on average 9%. LDL cholesterol lowered on average 5%. Insulin lowered on average 19%. Glucose lowered on average 4%.

30. Conclusion #2 Moderately high protein high red meat diets provide advantages in women. Greater weight, fat and midriff loss on high protein diet in those women with elevated TG. Greater lowering of plasma triglycerides on high protein diet in those women with elevated insulin or TG. Haemoglobin levels improved more on high protein high red meat diet. B12 status improved on high protein high red meat diet.

31. Conclusion #3 Moderately high protein diets can be a safe and effective option to conventional high carbohydrate weight loss diets. For some, HP diet may be easier to follow for longer periods as it may be more satisfying. HP diet as used in this study is safe and nutritionally adequate. It was easier to achieve RDI for all nutrients on HP diet.

32. Questions? Book 1 published in May 2005. Booklet released in August 2003 in the Australian Womens weekly, then as a free booklet by Meat & Livestock Australia (MLA).

33. www.csiro.au Thank You CSIRO Human Nutrition NameAssociate Professor Dr Manny Noakes TitleSenior Dietitian / Research Scientist Phone+61 8 8303 8827 Emailmanny.noakes@csiro.aumanny.noakes@csiro.au Webwww.csiro.au/twd Contact CSIRO Phone1300 363 400 +61 3 9545 2176 Emailenquiries@csiro.au Webwww.csiro.au