Category Archives: Weight Loss

November 22, 2009 · 2:00 AM

Low-Carb Ketogenic Diet for Overweight Diabetic Men: A Pilot Study

A low-carb ketogenic diet in patients with type 2 diabetes was so effective that diabetes medications were reduced or discontinued in most patients, according to U.S. researchers.  The 2005 report recommends that similar dieters be under close medical supervision or capable of adjusting their own medication, because the diet lowers blood sugar  dramatically. 

Methodology

Twenty-eight overweight people with type 2 diabetes were placed on the study diet and followed for 16 weeks.  Seven people dropped out, so the analysis involved 21, of which 20 were men—the study was done at a Veterans Administration clinic.  Thirteen were caucasian, eight were black.  Average age was 56; average body mass index was 42.  The seven dropouts were unable to come to the scheduled meetings or couldn’t follow the diet.  No dropout complained of adverse effects of the diet.

Results

Participants were instructed on the Atkins Induction Phase diet, which daily includes:

  • under 20 g carbohydrate
  • one cup of low-carb vegetables
  • two cups of salad greens
  • four ounces of hard cheese
  • unlimited meat, poultry, fish, eggs, shellfish
  • a multivitamin

At the outset, diabetes medication dosages were reduced in this general fashion: insulin was halved, sulfonyureas were halved or discontinued.  If the participant were taking a diuretic (fluid pill), low doses were discontinued; high doses were halved.

Study subjects returned every two weeks for diet counseling and medication adjustment (based on twice daily glucose readings and episodes of hypoglycemia).  Food cravings and/or good progress on weight goals triggered a 5-gram (per day) weekly increase in carbohydrate allowance.  In other words, if a participant’s weight loss goal was 20 pounds and he’d already lost 10, he could increase his daily carbs during the next week from 20 to 25 g.  Carbs could be increased weekly by five gram increments as long as weight loss progressed.  [This is typical Atkins.]   Food records were analyzed periodically.   

Results

  • hemoglobin A1c decreased from an average baseline of 7.5% down to 6.3% (a 1.2% absolute decrease and 16% relative drop)
  • the absolute hemoglobin A1c decrease was at least 1.0% in half of the participants
  • diabetic drugs were reduced in 10 patients, discontinued in seven, and unchanged in four
  • average body weight decreased by 6.6%, from 131 kg (288 lb) to 122 kg (268 lb)
  • triglycerides decreased 42%, while cholesterols (total, HDL, and LDL) didn’t change significantly
  • no change in blood pressures
  • average fasting glucose decreased by 17% (by week 16)
  • uric acid decreased by 10%
  • no serious adverse effects occurred
  • one hypoglycemic event involved EMS but was treated without transport
  • only 27 of 151 urine ketone measurements  were greater than trace

My Comments

The degree of improvement in hemoglobin A1c—our primary gauge of diabetes control—is equivalent to that seen with many diabetic medications.  I see many overweight diabetics on two or three drugs and a standard “diabetic diet,” and they’re still poorly controlled.  This diet could replace the expense and potential adverse effects of an additional drug.   

In August this year I blogged about a study comparing the Atkins diet with a traditional low-fat diet in overweight diabetic black women in the U.S.  As measured at three months, the Atkins diet proved superior for weight loss and glucose control.

This study at hand is small, but certainly points to the effectiveness of an Atkins-style very low-carb ketogenic diet in overweight men with type 2 diabetes.

Steve Parker, M.D.

Yancy, William, et al.  A low-carbohydrate, ketogenic diet to treat type 2 diabetes [in men].  Nutrition and Metabolism, 2:34 (2005).   doi: 10.1186/1743-7075-2-34

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November 17, 2009 · 2:00 AM

Self-Experimentation: Does Vinegar Promote Weight Loss?

MPj03878520000[1]I reported recently that apple cider vinegar in a Japanese study population reduced body weight by 2.2 to 4.4 pounds (1—2 kg) over 12 weeks.  The dose was 15—30 ml daily, or 1—2 tbsp.  The researchers think the active ingredient is simply acetic acid.

On November 14, 2009, I started another self-experiment: I’m drinking 7.5 ml (1.5 tsp) Heinz apple cider vinegar twice daily, mixing it in 8—10 fl oz of water plus 1/2 packet (1.75 g) of  Truvia sweetener, with or without 1 heaping tsp of sugar-free Metamucil.  I’ll do this for 12 weeks.  If I weighed over 200 lb, I would have chosen the 30 ml/day vinegar dose.  But I’m only 155 lb.

Why Truvia?  We had some in the house, I don’t think I absorb its erythritol and rebiana, and it makes the vinegar much more palatable. 

Why Metamucil?  You can figure that one out, Spanky.

A small-scale “experiment of one” like this isn’t worth much.  Too many variables can affect the outcome.  For instance, the holiday season is just around the corner.  Most Americans gain five pounds between Thanksgiving and New Years.  I’ve been no exception to that in the past. 

I’m not totally committed to the experiment.  But I’ve gotta do something with that huge bottle of vinegar my wife bought.   

Steve Parker, M.D.

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November 15, 2009 · 2:00 AM

Low-Carb Diet Helps Obese Swedes With Diabetes

Swedish boyObese people with type 2 diabetes following a 20% carbohydrate diet demonstrated sustained improvement in weight and blood glucose control, according to two Swedish physicians.  These doctors also have research experience with traditional low-fat diets in overweight diabetics, having demonstrated that a 20% carbohydrate diet was superior to a low-fat/55–60% carb diet in obese diabetes patients over six months.

What Was the Intervention?

Proportions of carbohydrates, fat, and protein were 20%, 50%, and 30% respectively.  Total daily carbs were 80–90 g. 

Recommended carbs were vegetables and salads. 

Rather than ordinary bread, crisp/hard bread was recommended (3.5 to 8 g carb per slice).  Starchy breads, pasta, potatoes, rice, and breakfast cereals were excluded. 

They were instructed to walk 30 minutes daily, take a multivitamin with extra calcium daily, and to not eat between meals. 

At the outset, diabetic medications were reduced by 25–30% to avoid low blood sugars.   

Results

The doctors followed 23 patients over the course of  44 months.  Average initial body weight was 101 kg (222 pounds).  After 44 months, average body weight fell to 93 kg (205 pounds).  Hemoglobin A1c, a measure of diabetes control,  fell from 8% to 6.8%. 

My Comments

In these pages over the last few months, we’ve seen the effectiveness of low-carb diets in people with type 2 diabetes in widespread populations: Japanese, U.S. blacks and caucasions, and, now, Swedes. 

The standard Western diet derives 55–60% of its energy from carbohydrates.  If you’ve been following this blog, we’ve looked at diets containing 40%, 30%, 20%, and 10% carbs.  Have you noticed the trend? 

Reducing the percentage of carbohydrates in the diet improves diabetic control and loss of excess weight.  And the more you reduce carbs, the greater the degree of diabetic control and weight loss.   

Steve Parker, M.D.

Reference:  Nielsen, Jörgen and Joensson, Eva.  Low-carbohydrate diet in type 2 diabetes: stable improvement of body weight and glycemic control during 44 months follow-up.  Nutrition & Metabolism, 5:14   doi:10.1186/1743-7075-5-14

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November 11, 2009 · 2:00 AM

Drink Vinegar and Lose 2-4 Pounds Effortlessly

CB052540Japanese researchers recently documented that daily vinegar reduces body weight, fat mass, and triglycerides in overweight Japanese adults. 

Beverages containing vinegar are commonly consumed in Japan.  The main component—4 to 8%— of vinegar is acetic acid.  Vinegar can lower cholesterol levels, lower blood pressure, and limit increases in blood sugar after meals. 

Japanese researchers studied the effects of vinegar on 175 overweight—body mass index between 25 and 30—subjects aged 25 to 60.  Men totaled 111; women 64.  Average weight 74.4 kg (164 pounds).  They were divided into three groups that received either a placebo drink, 15 ml apple vinegar (750 mg of acetic acid), or 30 ml apple vinegar (1,500 mg acetic acid).  Placebo and vinegar were mixed into 500 ml of a beverage, half of which was drunk twice daily after breakfast and supper for 12 weeks.  Changes in body fat were measured with CT technology.  Subjects were told to eat  and exercise as usual.   

Results

By the end of the 12 weeks, weight had decreased by 1-2 kg (2.2 to 4.4 pounds) in the vinegar drinkers, with 30 ml of vinegar a bit more effective.  CT scanning showed that the lost weight was fat mass rather than muscle or water.  Triglyceride levels in the vinegar groups fell by about 20%.  The placebo drinkers saw no changes. 

Four weeks after the intervention ended, subjects were retested: values had returned to their baseline, pre-study levels. 

The scientists report that the acetic acid in vinegar inhibits production of fat and may stimulate burning of fat as fuel.  Although vinegar contains many other ingredients, they think the acetic acid is responsible for the observed changes.

My Comments

It’s possible that apple vinegar components other than acetic acid led to the weight loss and lowered triglyceride levels.  Further study could clarify this.

These results may or may not be applicable to non-Japanese races.

This study supports the use of vinaigrette as a salad or vegetable dressing in people trying to lose weight with diets such as the Ketogenic Mediterranean Diet.  Vinaigrettes are combinations of olive oil and vinegar, often with various spices added.  If you eat a salad twice a day, it would be easy to add 15 ml (1 tbsp) of vinegar to your diet daily. 

With a little imagination, you could come up with other ways to add 15–30 ml (1–2 tbsp) of vinegar to your diet.

Steve Parker, M.D.

Reference:  Kondo, Toomoo, et al.  Vinegar intake reduces body weight, body fat mass, and serum triglyceride levels in obese Japanese subjects.  Bioscience, Biotechnology, and Biochemistry, 73 (2009): 1,837-1,843.

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November 8, 2009 · 10:19 AM

Eat Cod to Lose More Weight

BUS30079Five servings of cod per week led to loss of an extra 3.7 pounds (1.7 kg) over eight weeks, according to a recent research report. 

European researchers noted that cod consumption in a prior study increased weight loss.  They wondered if that result could be reproduced, and whether the effect was “dose dependent.”  In other words, would those eating more cod lose more weight than those eating less?

They studied 125 subjects between the ages of 20 and 40, with body mass index between 27.5 and 32.5.  The abstract doesn’t mention sex of the participants.  They were all placed on calorie-restricted diets with identical percentages of protein, fat, and carbohydrate, and were followed for eight weeks.  Researchers divided the subjects into three groups:

  1. One group was given 150 g (a little over 5 ounces)  of cod three times weekly
  2. Another group was given 150 g cod five times weekly
  3. The third group was given no seafood

Average weight loss overall was  11 pounds (5 kg).  The more cod consumed, the greater the weight loss.  Those eating five servings a week averaged 3.7 pounds (1.7 kg) more than the group not eating seafood. 

It’s unclear whether other types of fish would produce similar results.

These results support the prominent role of fish in the Ketogenic Mediterranean Diet. 

Steve Parker, M.D.

Reference:  Ramel, A., et al.  Consumption of cod and weight loss in young overweight and obese adults on an energy reduced diet for 8-weeks.  Nutrition, Metabolism and Cardiovascular Diseases, 19 (2009): 690-696.

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November 4, 2009 · 9:00 AM

How Much Is a Good Reputation Worth?

42-15614410

"No weight-loss supplements for me!"

Recommended reading:

Janet Helm at her Nutrition Unplugged blog yesterday wrote about fitness guru Jillian Michaels’ endorsement of highly questionable weight-loss supplements. 

Steve Parker, M.D. 

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August 15, 2009 · 10:33 AM

Atkins Diet Beats Low-Fat Diet Over Three Months in Overweight Diabetic Black Women

MPj04384250000[1]A recent study compared effects of a low-carb versus low-fat diet in overweight diabetics (mostly blacks).  After one year, the only major difference they found was  lower HDL cholesterol in the low-carb eaters.  The low-carb diet was more effective measured at three months into the study.  Study participants were overwhelmingly black women, so the findings may not apply to you.

Background

The authors note at the outset that:

Optimal weight loss strategies in patients with type 2 diabetes continue to be debated, and the best dietary strategy to achieve both weight loss and glycemic control . . . is unclear.

They also note that in short-term randomized studies, low-carb diets help improve glucose control in type 2 diabetics.

Methodology

Participants (105) were randomized to either:

  • a low-fat diet in the fashion of the Diabetes Prevention Program, with a fat gram goal of 25% of energy needs, or . . .
  • the Atkins diet, including the 2-week induction phase and gradually increasing carb grams weekly, etc.

The adult partipants were black (64%), Hispanic (16%), white (15%), or other.  Women were 80% of the group.  Average age 54.  Average weight 215 pounds (98 kg).  Average BMI 36.  Most of them were taking metformin, half were taking a sulfonylurea, 30% were on insulin.  Thiazolidinedione drugs were discontinued since they cause weight gain as a side effect.  Short-acting insulins were changed to glargine (Lantus) to help avoid hypoglycemia.  For the low-carb group initially, insulin dosages  were reduce by half and sulfonylureas were stopped (again, to minimize hypoglycemia).  For the low-fat group, insulin was reduced by 25% and sulfonylurea by 50%.  Metformin was not adjusted.  Subjects were instructed to keep daily food diaries.  Goal rate of weight loss was one pound per week.   

Results

The drop-out rate by the end of 12 months was the same in both groups – 20%.  The low-carbers lost weight faster (3.7 lb/month) in the first three months, but by month twelve each group had the same 3.4% reduction of weight (6.8 lb or 3 kg).  As measured at 3 months, low-carbers were down 11.4 lb (5.2 kg) and low-fat dieters were down 7 lb (3.2 kg).  Maximum weight loss was at 3 months, then they started gaining it back.  At 12 months, low-carb subjects using insulin were on 10 less units, while low-fat dieters were using 4 more units (not statistically significant).  Hemoglobin A1c measured at 3 months was down 0.64 in the low-carb group and down0.26 in the low-fat.  By 12 months, HgbA1c’s were back up to baseline levels for both groups.  Blood lipids were the same for both groups at 12 months except HDL was about 12% higher in the low-carb dieters.

At baseline, subjects derived 43% of calories from carbohydrates, 36% from fats, 23% from proteins.  At three months, the low-carb group ate 24% of calories as carbohydrates (estimated at 77 grams of carb daily) and 49% from fat.  The low-fat group at 3 months derived 53% of calories from carbohydrate (199 grams/day) and 25% from fat. Diet compliance deteriorated as time passed thereafter. 

Study Author Conclusions

After one year, the low-carb and low-fat groups had similar weight reductions.  The low-carb dieters raised their HDL cholesterol levels significantly [which may protect against heart disease].

My Comments

Lasting weight loss is difficult!  Down only 6.8 pounds for a year of  effort. 

These study participants needed to lose a lot more than 6.8 pounds.  They needed to lose 50.  Both groups were woefully noncompliant with diet recommendations by the end of the study year.  They were eating more carbs or other calories than they were assigned.  But their results weren’t much different than other groups studied for an entire year. 

How do we keep people fired up about maintaining their weight-loss efforts?  The solution to that problem will win someone a Nobel Prize.

The Atkins diet was superior – for weight loss and glycemic control – when measured at three months, when compliance by both groups was still probably fairly good.

Results of this study may apply only to black women.  There weren’t enough men and other ethnic groups to make meaningful comparisons.    

Steve Parker, M.D.        

Reference:  Davis, Nichola, et al.  Comparative study of the effects of a 1-year dietary intervention of a low-carbohydrate diet versus a low-fat diet on weight and glycemic control in type 2 diabetes.  Diabetes Care, 32 (2009): 1,147-1,152.

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July 1, 2009 · 2:00 AM

Does Weight Loss Prevent Type 2 Diabetes?

Finger-pricking four times a day gets old real quick!

Finger-pricking four times a day gets old real quick!

I found an interesting statistic in a scientific journal article last year:

Every 2.2 pound (1 kg) loss of excess weight lowers the risk of developing type 2 diabetes by 16%.

That tidbit was embedded in another article with a focus on regain of lost weight over time.  The “16% per kilogram” number sounded too good to be true, and I had never heard it before.  So I did some digging and found the source of the statistic.  Ain’t the Internet wunnerful?

The origin of the 16% figure is the Diabetes Prevention Program Research Group.  Investigators enrolled 1,079 middle-aged (mean 50.6 years) study participants and followed them over 3 years, noting the effects of exercise, percentage of fat in the diet, and weight loss on the subsequent development of diabetes.  Average body mass index was 33.9.  (A 5-foor, 4-inch person weighing 197 pounds (89.5 kg) has a BMI of 33.9).  Sixty-eight percent of participants were women.  The investigators’ goal for this group of overweight people was for loss of 7% of body weight through diet, physical activity, and periodic counseling sessions.  Average weight loss over the course of three years was 9 pounds (4.1 kg).

None of the study participants had diabetes at the time of enrollment.  But, by design, they all had laboratory-proven “impaired glucose tolerance.”  Impaired glucose tolerance is a form of “pre-diabetes.”  It is determined by giving a  75-gram dose of glucose by mouth, then measuring blood glucose (sugar) 2 hours later.  A blood glucose level under 140 is normal.  If the level is 140-199, you have impaired glucose tolerance.

Having impaired glucose tolerance means that study participants’ glucose (sugar) metabolism was already abnormal.  They were at higher than average risk of developing diabetes, compared with both average-weight healthy people and overweight people without impaired glucose tolerance.  This is a great cohort to study for development of diabetes.  But the finding that “every 2.2 pounds of weight loss lowers the risk of diabetes by 16%” applies to this particular group with impaired glucose tolerance, not the general overweight population.

A total of 153 participants developed diabetes over the course of 3 years.  Loss of excess weight was by far the best predictor of lowered diabetes risk, compared with regular exercise and lowering percentage of dietary fat.

Yes, weight loss does prevent diabetes in some, probably many, overweight people.  The specific degree of reduced risk depends on numerous factors, such as age, sex, genetics, degree of weight loss, and pre-existing impaired glucose tolerance.

Steve Parker, M.D.

Reference: Hamman, Richard, et al.  Effect of Weight Loss With Lifestyle Intervention on Risk of Diabetes.  Diabetes Care, 29, (2006): 2,102-2,107.

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June 30, 2009 · 2:00 AM

Are High-Protein Weight-Loss Diets Safe and Effective?

Animal protein

Animal protein

According to researchers at Tufts University, high-protein weight-loss diets may be effective and safe except for people prone to kidney stones, chronic kidney disease, and people with diabetes.  Long-term effects on bone health – osteoporosis, specifically – might be a problem.

High-protein weight-loss diets have been popular for a while.  “Protein Power” by Drs. Michael and Mary Eades is an example.  The Atkins diet may be, too.  If you increase the protein in your diet, you generally are decreasing carbohydrates or fat, or both, at the same time.   

I found a scientific review article from way back in 2002 and thought I’d share some of the highlights.  The authors seem very thorough; the article has 150 citations of other research articles. 

Note that the RDA – recommended dietary allowance – for protein is 0.8 gm/kg.  The typical U.S. resident eats about 1.2 gm/kg of protein daily, which is about 15% of total energy (calorie) intake.   Public health agencies recommend that we get 15% of our energy from protein, 30% from fat, and 55% from carbohydrate.  The authors of the study at hand propose that a high-protein diet be defined as:

  • protein intake of at least 25% of energy in weight-stable individuals, or
  • at least 1.6 gm/kg (of ideal body weight)  in people actively losing weight

Here are some of the authors’ points I found interesting:

  1. Higher-protein meals do seem to suppress hunger and enhance satiety, so high-protein dieters probably eat less (average 9% less calories).  It’s unknown if the effect lasts longer than six months.  Most of the evidences is much shorter-term.
  2. High-protein intake increases the thermic effect of feeding, meaning energy expenditure increases simply as a result of eating protein.  In other words, it takes energy to process the food we eat.  Compared with fats and carbohydrates, protein contributes twice as much to the thermic effect of feeding.  Most of the thermic effect of protein results from protein synthesis, i.e., the production of new proteins, which requires energy.  This has a minimal influence on body weight. 
  3. The authors write that “these studies do not support a role for high dietary protein in preventing loss of lean tissue during negative energy balance [actively cutting calories to lose weight], provided that dietary protein intake at least meets the RDA.”   
  4. They found only one study comparing a high-protein diet (25% of calories) with a low-fat, high-carbohydrate diet (12% protein).  Both diets were 30% fat.  Both groups could eat all they wanted.  Weight and fat loss were greater in the high-protein group, about twice as much. 
  5. High-protein diets over the long run may cause low-grade metabolic acidosis, leading to net loss of body calcium through the urine, with associated weak bones and kidney stones.   Animal proteins in particular do this.  Bone loss may be alleviated by calcium supplementation.  Fruits and vegetables may counteract the acidosis effect.  Nearly all of these statements are based on short-term studies.
  6. People with chronic kidney disease (ask your doctor) have slower disease progression and live longer if they limit protein to the RDA level. 
  7. Animal protein intake is directly related to risk of symptomatic kidney stones.
  8. Protein produces a blood glucose response, although not as much as with carbohydrate.  Insulin response is also seen.  In type 2 diabetics, the insulin response to 50 grams of animal protein was the same as to 50 grams of glucose.  A few studies suggest that in type 2 diabetics a high-protein diet may be detrimental to glucose control and/or insulin sensitivity.  Also note that people with diabetes are prone to chronic kidney disease, which could be worsened with a high-protein diet.  

Take-Home Points

See first paragraph.  The article authors may have different opinions now, based research published over the last seven years. 

Steve Parker, M.D.

Reference:  Eisenstein, Julie, et al.  High-protein weight-loss diets:  Are they safe and do they work?  A revew of the experimental and epidemiologic data.  Nutrition Reviews, 60 (2002): 189-200.

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June 24, 2009 · 2:00 AM

High Protein Ketogenic Diet Beats High Protein/Medium Carb Diet in Men, at Least Short-Term

Low-Carb Steak

Low-Carb Steak

Scottish researchers last year reported greater weight loss and less hunger in obese men on a high-protein ketogenic diet compared to a high-protein, moderate-carbohydrate diet.

Background

Dietary protein seems to be more satiating – able to satisfy hunger, that is – than carbohydrate and fat. 

The typical Western (especially American) diet derives about 55-60% of total calories from carbohydrates.  When carbohydrate intake is very low, under 20-30 grams per day for example, fat stores are utilized as a source of energy to replace carb calories, resulting in fat breakdown waste products called ketone bodies.  These are ketogenic diets.  In them, carbs are replaced usually by both extra fat and extra protein. 

Methodology

Each of 17 obese men, 20 to 65 years old, were placed on two separate diets for four weeks each time.  Average weight was 111 kg.  Average body mass index was 35.  This was a residential program, but the subjects were allowed to leave and go to work.

  • Diet 1:  high-protein, low-carbohydrate, ketogenic.  30%, 4%, and 66% of energy (calories) as protein, carbohydrate, and fat, respectively.
  • Diet 2:  high-protein, medium-carbohydrate, nonketogenic.  30%, 35%, and 35% of calories as protein, carb, and fat, respectively.

Actually 20 men signed up, but three dropped out for personal reasons after starting. 

They could eat as much as they wanted. 

Results

Subjects had no overall preference for either diet.  No differences in the diets for desire to eat, preoccupation with food, or fullness.  Weight loss was greater for the low-carb diet tahn with the medium-carb diet: 6.34 kg vs 4.35 (P < 0.001).  Subjects lost more weight on their first diet than on their second.  Fasting glucose and HOMA-IR (a test of insulin resistance) was lower than baseline for the low-carb diet but not the other.  Total and LDL cholesterol were tended to fall in response to both diets, but to a statistically significantly great degree only on the medium-carb diet.  When eating the low-carb diet, subjects ate 300 calories per day less than on the medium-carb diet.  [ketones were measures?]

Discussion

We have to assume that study subjects were of Scottish descent.  Applicability of these results to other ethnic groups is not assured.  Similarly, results don’t necessarily apply to women.

I’m surprised the medium-carb dieters, eating all they wanted, lost weight at all.  Must be a result of the high protein content or lower-than usual carbohydrate content of the study diet.  Study authors cite others who found that doubling protein intake from 15 to 30% of calories reduces food intake, which should lead to weight loss. 

Since protein content was the same on both diets, the greater weight loss seen on the low-carb ketogenic diet was the result of lower caloric intake, in turn due to less hunger.  The reduced energy intake could be due to lower carb or higher fat intake, or both.  The researchers cite one study finding no satiating effect of fat.  Some say that ketone bodies reduce appetite. 

Although the medium-carb diet showed greater improvements in total and LDL cholesterol, the low-carb diet changes trended in the “right” direction (down).

On the low-carb ketogenic diet, lower glucose levels and insulin resistance would tend to help people with (or prone to) type 2 diabetes, prediabetes, and some cases of metabolic syndrome. 

Steve Parker, M.D.

 References: 

Johnstone, Alexandra, et al.  Effects of a high-protein ketogenic diet on hunger, appetite, and weight loss in obese men feeding ad libitum.  American Journal of Clinical Nutrition, 87 (2008): 44-55.

Weigle, D.S., et al.  A high-protein diet induces sustained reductions in appetite, ad libitum caloric intake, and body weight despite compensatory changes in diurnal plasma leptin and ghrelin concentrations.  American Journal of Clinical Nutrition, 82 (2005): 41-48.

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