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17 4 A m J C lin N utr 1996;6 3 :1 74-8 . P rin ted in U SA . 1996 Am erican S oc iety for C lin ica l N utr itio n

S im ila r w e igh t lo ss w ith low - o r h igh -ca rbohyd ra te 2A la in G o la y , A nne -F ran# {231}o ise A lla z , Y ves M o re l, N ico la s deG era ld R eaven

ABSTRACT T he go a l o f th is stud y w as to eva lua te the effec to f d ie ts tha t w ere eq ua lly low in energ y bu t w ide ly d iffe ren t inre la tiv e am ounts o f fat an d carbohydra te on body w eigh t during a6-w k p eriod o f h osp ita liza tion . C onsequ en tly , 43 ad u lt, o beseperso ns w ere rand om ly ass igned to rece ive d iets con ta in in g 4 .2M J/d (10 00 kca l/d ) com po sed of e ithe r 32% pro te in , 1 5% carbo-hyd ra te , and 53% fa t, o r 29% p ro tein , 45% carb ohydrate , and 2 6%fa t. T here w as no s ig n ifican t d iffe rence in the am ount o f w eigh tloss in respo nse to d ie ts co n tain ing e ithe r 1 5% (8 .9 0 .6 k g) o r45% (7 .5 0 .5 k g) ca rbo hyd rate . F ur the rm o re, sig n ifican t d e-cre ase s in to tal b od y fat an d w aist-to -h ip circum fe ren ce w ere seenin bo th groups , an d the m agn itude of th e chang es d id no t vary asa fun c tion of d ie t com pos ition . F asting p lasm a g lucose , insu lin ,cho leste ro l, and tr iacy lg lycero l co ncen tra tion s decreased s ign ifi-can tly in pa tien ts ea ting low -energy d ie ts tha t con ta in ed 1 5%carbohyd ra te , bu t n e ithe r p lasm a insu lin n or triacy lg lycero l con-cen tra tions fe ll s ign ifican tly in respon se to the h igh er-ca rb ohydrated ie t. T he re su lts o f th is stud y show ed th at it w as en ergy in take , n o tnu trien t com position , tha t de term in ed w eigh t loss in respo nse tolow -energ y d iets ov er a sh ort tim e period . Am J C lin N u tr1996 ;6 3: 174 -8 .

K EY W ORD S O bes ity , w e ig h t loss , low -carb ohyd ra ted ie t, h igh-ca rbo hydra te d ie t

I NTRODUCT ION

A lth ough there is little a rg um ent th a t ob es ity cons titu tes ahea lth h aza rd (1 -4 ) , th ere a re w ide ly d ifferen t op in ions w h ena tten tion is focused on how to bring abou t w eigh t loss in ob eseind iv idua ls. W hen eva lua ting th e efficacy of w eigh t-loss p ro -g ram s it is necessa ry to d iffe ren tia te be tw een cons idera tion s ofthe re latio n b etw een chang es in ene rgy b alance and w e igh t lo s s(5 , 6), the ab ility o f ind iv idua ls to com ply w ith a w e igh t- lo ssd ie t (7 ) , and th e long -te rm success o f an y w e igh t-lo s s p rog ramin p rev en tin g a re tu rn to the orig ina l w eigh t (8 -10 ). T he first o fth e se is sues app ea rs to b e th e m ost stra igh tfo rw ard , bu t even inthis in s tance , con sensus has no t been reached . For exam ple , ithas been arg ued tha t low -fa t d ie ts lead to be tte r w eigh t loss( 1 1), b u t da ta from A lfo rd e t a l (12 ) in d ica te tha t b o th w e igh tlo ss and changes in asso cia ted m etabo lic variab les w ere s im ila rwhen p atien ts w ere p re sc ribed 5 .0 -M J/d (120 0-kcal/d ) d ietsco n tain ing low , m odera te , and h igh proportions of ca rbo hy-d ra te. T he presen t stud y w as in itiated to ex tend these o bserv a-tions , and invo lv ed a com pariso n in 43 obese pa tien ts o f thech an ges in w eigh t an d severa l facets o f ca rbohydra te and

T onn ac , Sve ta lina Tan ko va , a nd

lip opro te in m etabo lism th a t fo llow ed the in itiation of low -energy d ie ts con sis ting of e ithe r 15% o r 45% of energy fromca rbo hydra te . T o inc rease d ieta ry com pliance, p atien ts w ereho sp ita lized fo r th e en tire d u ra tion of the stu dy , d u rin g w hichtim e th ey a lso rece ived beh av io ra l and nu tritiona l educa tion .

SUBJECTS A N D METH OD SFo rty -th ree ad u lt, ob ese pa tien ts w ere s tud ied be fo re an d

a fte r a 6 -w k pe rio d of ho sp ita lizatio n . T hese su b jects had beenrefe rred to th e O b es ity O u tpa tien t C lin ic o f th e D epa rtm en t o fM ed ic ine a t G eneva U n ive rsity H osp ita l fo r d ie ta ry treatm en to f the ir o besity .

D uring the firs t v is it, it w as decid ed on the b asis o f a h is to ryof fa ilu re to lo se w e igh t in re spo nse to am bu la to ry treatm en ttha t the se ind iv idua ls w ou ld bene fit if th ey w ere h osp ita lizedfo r th e firs t 6 w k o f trea tm en t. C rite ria fo r adm is sion inc lud eda body m ass index (kg /rn2 ) > 30 , stron g persona l m otiva tion ,and th e ab ility to pa rticip ate in the requ is ite am oun t o f p hysica lactiv ity . P a tien ts w ith ob esity secon da ry to en doc rine d isea se,as w ell as those w ith p sych ia tric d iagnoses, w ere exc lu dedfrom the stud y . Th e p ro toco l w as subm itted to an d accep ted bythe e th ica l comm ittee o f the D ep ar tm en t o f M ed ic ine a t G enev aU n iv ersity H osp ita l.

In add itio n to a low -ene rg y d ie t, su b jects p artic ip a ted in astruc tu red , m u ltid iscip lina ry p rogram th a t inc luded phy sica lactiv ity , nu tritiona l educa tio n , and standard behav io ra l tech -n iques . E xerc ise co nsis ted of 1 h of aerob ic exerc ise tra in in gpe r day and 1 h of un de rw a te r phy sical ac tiv ity pe r day .N u tr itiona l ed uca tion w as p rov ided b y a reg iste red d ietitiantw ice a w eek (o nce in a g roup sess ion and once ind iv idu a lly ).T h e b ehav io ra l app ro ach consis ted o f s ix se ssion s, du rin gw h ich is sues o f se lf-con tro l, cog n itive res truc tu ring re in fo rce -m en t, and relapse p rev en tion w ere addre ssed .

O n adm iss ion to the hosp ita l, pa tien ts w ere rand om ly as-signed to rece ive d ie ts con ta in ing 4 .2 M i/d (100 0 k ca l/d ) tha tcons is ted of e ithe r 15% or 45% of energ y as carb ohyd ra te .

I F rom the D epa rtm ent of M ed icine, G en ev a U n ive rsity H osp ita l, a ndStanfo rd U niversity S choo l o f M edicin e and G er ia tric R esearch , Educa tionand C lin ical C enter , D epar tm ent of V eterans A ffairs M edical C en ter , Pa loA lto , CA .

2 A ddress reprin t req ues ts to A Go lay , D iab ete s T reatm en t an d T each in gU nit, D epar tm ent o f M edic ine, U niv ersi ty o f G enev a H o spita l, 1 21 1 ,G en ev a 1 4 , Sw itz erland .

R ece iv ed N ov em ber 14 , 1 99 4 .A ccep ted fo r p ub lica tio n O cto be r 17 , 19 95 .

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W E IGH T LO SS W ITH LOW - OR H IGH -CARBOHYDRATE D IET S I 75

E SD . B P , b lo od p res sure .

B ase lin e ch arac te ristic s o f the tw o experim en ta l g ro ups arelisted in T able 1. T he group s w ere com parab le in term s of sexd istribu tion , age , body m ass in dex , and b lo od pressu re .

A fte r base line m e tabo lic da ta w ere acq u ired , th e pa tien tsw ere sta rted o n one of th e tw o experim en ta l d iets . C om po si-tions of the tw o d ie ts a re show n in T able 2. Both d ie ts con-sisted of n atu ral food s. Recip es an d m enus of variou s fooditem s w ere stand ard ized . A 7-d ro ta tio na l m enu w as used . T h em enus prov id ed s im ila r nu trien t com pos ition b u t o ffe red d i-ve rse foo ds. Item ized com pos ition s o f m ea ls f rom I d o f thero ta tio n m enu for the low -carboh ydra te and h igh-ca rb ohyd ra ted ie ts a re g iven in T able 3.

D aily energ y in take w as d istribu ted am ong breakfas t ( 2 2%) ,lu nch (33% ), d inner (33% ), and bed tim e snack (12% ). T h eto tal energy an d pro te in con ten ts o f th e tw o d ie ts w ere s im ila r.En ergy in take w as care fu lly m easured fo r each p atien t. A llsub jec ts w ere ins truc ted to ea t all fo ods and a d ie titian w aspresen t du ring each m ea l to im prov e com pliance . T o verifycom pliance w ith the d ie t, pa tien ts com pleted a l-d foo d recordonce a w eek during the 6 w k of the study . T hese fo od recordsto ok th e qua lity and th e quan tity o f fo od consum ed in to ac -co un t. T he softw are PROD I3+ w as used to ca lcu late a lim en-ta ry p lans and food record s (13). Fo od com po sition tab les u sedw ere f rom Souc i e t a l (14 ) an d R en aud and A ttil (15 ).

T he abso lu te am oun t o f ca rb ohydra te w as th ree tim es h ig he rin the 45% -carboh ydra te d ie t than in the 15% -carbohyd ra te d ie t(1 1 5 14 com pared w ith 37 S g), and th e am oun t o f fa t w asles s in the 45% -carbohyd ra te d iet (3 0 5 com pared w ith 6 0 5 g ). B o th d ie ts con ta ined sim ilar am oun ts o f sa tu ra ted fa t( 14 g /d ) and cho les te ro l ( 230 m g/d) .

B lo od w as draw n after a 14-h ove rn igh t fast be fo re an d a fte r6 w k o f the low -en ergy d ie ts fo r m easu rem en ts o f p lasm ag lucose ( 1 6 ), p lasm a im m unoreac tive insu lin ( 1 7 ), c ho le st er ol( 1 8 ), h igh -d en sity - lipop ro tein (H D L )-cho les tero l, and triacy l-g ly ce ro l co nc en tra tio ns ( 1 9). N itrogen b a lan ce w as m easu redto com pare th e pro te in -sp ar in g effect o f th e tw o low -en ergyd ie ts. U rina ry n itrogen w as m easured b y the K je ldah l m etho d(20) .

Tw en ty -fou r-hou r u rin e sam p les w ere co llec ted eve ry w eekan d ave rag e d aily u rin ary los s w as com pu ted on the b asis o fth ese six co llec tions . In teg um enta l and stoo l losses w ere esti-m ated o n the b as is o f p rev ious ly reported s tud ies: 5 and 10m g /kg body w t, respec tiv ely (2 1). D aily n itro gen ba lance w ascalcu la ted by sub trac ting to ta l o u tpu t (u rine , s to o l, and in teg -um ental losses) from die ta ry in pu t.

Body fa t com positio n an d pe rcen tage o f ad iposity w erede term in ed by tw o d ifferen t techn iq ues: sk in fo ld - th icknessm easurem en ts a t b iceps, triceps, sub scapu la , an d suprailiac

T ABL E 1P hy sic al ch arac ter istics of th e sub jec ts

15 %(F1

Carbohydrate3M , l9F )

45 %(n

Carbohydrate6M , 1SF)

A ge(y) 419 4518W eight (kg) 10 7 23 102 18H eig ht (cm ) 162 9 16 4 9BM I (k g/m 2 ) 4 1 9 38 5Systo l ic BP (mm H g) 138 14 136 18D ias to lic BP (m m H g) 89 9 85 14

T AB L E 2C om pos itio n of d ie ts

1 5% C ar bo hy dr at e 4 5% C ar bo hy dr ateEnergy (kI/d) 4214 31 5 4296 32 0Carbohydra te

(g /d ) 375 11514(% ) 1 55 455

Fa t(g /d ) 605 305(% ) 535 265

Pro te in(g ld ) 799 735(% ) 325 295: SD .

(2 2), and b ioe lec trica l im pedance ana ly sis (23) . B ody com po-s ition va lues as assessed by these tw o techn iqu es w ere s ig n if-ican tly co rre la ted and lin ear (r = 0 .64 , P < 0 .0001). Percen t-age o f fa t w as expressed as a m ean of th ese tw o m easurem en ts(sk in fo ld th ickness and b ioe lec trica l im pedance).

Data a re expres sed as m eans SEM s and w ere an aly zedw ith th e genera l-linear -m ode ls p roced ure o f SA S (SA S Ins ti-tu te m c , C ary , N C ). T o eva lu ate the d iffe rence be tw een the tw og roups o f obese p atien ts, b e fo re an d afte r w eig h t loss , d ataw ere an aly zed b y tw o-w ay an aly sis o f va riance , w ith the m ul-tip le-com parison approach o f S cheff#{233} (2 4 , 25).

RESULTS

V alues fo r to ta l body w eigh t, b ody fa t, w a ist and h ip cir-cum ferences, and w ais t-to -h ip ra tio befo re th e d ie ts a re g ivenin T able 4. T hese values wer e not s ig n ifican tly d iffe ren t be-tw een th e tw o g ro ups a t base line nor w as th ere a sign if ican td iffe ren ce in the am oun t o f w eig h t lo s s in resp onse to d ietscon ta in ing e ithe r 15% o r 45% carbohyd ra te . Fur th erm ore , to ta lbody fa t, w a ist an d h ip c ircum ference , and w aist-to -h ip ra tiodecreased sign if ican tly in bo th g roups , and the m agn itu de o fthe chang es d id n o t vary as a fu nc tion of d ie t com position . T hepercen tage w eigh t loss and the percen tage fa t loss w ere m oresim ilar in the tw o grou ps than w ere the ab so lu te chang es .

D a ily d ie ta ry n itrogen in take w as sim ilar [12 .6 0 .3 g(1 5 % -ca rboh ydra te d iet) com pared w ith 1 1 .7 0 .2 g (45% -carbohyd ra te d iet)] and n itrogen losses w ere n o t sign ifican tlyd iffe ren t [1 3 .9 1 .7 g (15% -carb ohyd rate d iet) com pared w ith1 1 .2 0 .9 g (45% -carbo hyd ra te d ie t)] b etw een grou ps. T hepro te in -sp ar in g effec t o f bo th d ie ts w as equ al: n itro gen ba lancew as 1 .3 0 .5 (15% -carbohyd ra te d ie t) com pared w ith -0 .5 0 .6 g (45% -ca rboh ydra te d ie t). N itro gen ba lance w as m orenega tive w ith each d ie t du rin g the fir st w eek F - I .5 0 .2 (15%carb ohydrate ) and - 1 .8 0 .2 g (45% carbohydra te) ] thanduring the last S w k.Table 5 lis ts va lues fo r fas ting p lasm a g lucose , in su lin ,

ch o le ste ro l, HD L -cho leste ro l, an d triacy lg ly ce ro l con cen tra -tions b efo re and af te r the d ie ta ry in te rven tion , an d sh ow s tha tthese in dexes w ere no t s ign ifican tly d iffe ren t be tw een the tw ogroups befo re d ie ting . T hese da ta a lso sh ow tha t fas ting p lasm ag lucose , insu lin , cho leste ro l, H D L -cho les tero l, and triacy lg lyc -e ro l concen tra tions decreased s ign ifican tly in p atien ts ea tingthe low -en ergy d ie ts, w h ich co n ta in ed 15% carbohydra te . A l-tho ug h trend s in a s im ila r d irectio n w ere seen w hen pa tien ts a te

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T ABL E 3I tem iz ed com po sition of die ts

Food item s

D I SCU SS ION

1 5% C ar bo hy d ra teB r e a k f a s t

L ow -f at f re sh cheese (20% f at)Lo w- f a t h a m

LunchL ow -fat m eat or f ishV ege tab leOi l

SnackL ow -fat, artif icially sw ee ten ed y ogurt

D i n n e rL ow- f a t m eat or egg sV e ge t a b l eW hole -w heat b readO il

S n a c kL ow -fat f resh chee se (20% f at)

4 5% C arb oh y drat eBreak fa s t

L ow -f at sk im m ed m ilk (0% fat)W ho le -w heat b readB utter o r m arg arin e

L u n c hL ow -f at m eat o r f ishV e ge t a b l eR ice, pasta, or cerealsFruitOi l

SnackL ow -f at, artif ic ially sw ee tened y og urt

Di n n e rL ow -f at m eat o r eggsV e ge t a b l eR ice, pasta, or cerealsOi lSnackL ow- f a t f resh cheese (20% fat)Fruit

th e low -energy d ie ts con tain ing 45% carb ohy drate , the m agn i-tu de o f the d if f e rences w as atten uated an d ne ither p lasm ainsu lin nor triacy lg ly cero l co ncen tration s f e ll s ig n if ican tly inre spon se to the h igher-carbo hy drate d ie t.

17 6 GOL A Y ET A L

In th is stu dy w e ev aluated th e e f f ects o f low -energy d iets thatW eigh t v aried subs tan tially in the ir relativ e proportions o f f at and

g carbohy d rate on both w eigh t lo ss and v ariou s m etabolic end-po in ts . T h e am oun t o f w eigh t lo ss w as sim ilar in resp onse to

150 the tw o d ie ts , an d w as apparen tly in dependen t o f the am oun t o f50 f at o r carbohy drate in the tw o te st d ie ts , b eing re lated m os t

c lo se ly to to tal energy in tak e (T ab le 3 ). O n th e o th er hand ,10 0 v ariation s in d ietary com pos ition d id app ear to m od if y the10 0 bene f ic ial e f f ec ts o f w e igh t loss on certain m easures o f carbo -

hy d rate and lip id m e tab o lism . M ore spec if ically , th e f all in180 f as ting p lasm a g lu co se , in su lin , ch o le ste ro l, triacy lg ly cero l,and HD L -cholestero l concen tratio ns w as decreased in subjects10 0 eatin g a low -energy d ie t re lativ ely h ig h in carbohy drate, and100 the changes in p lasm a insu lin and triacy lg ly cero l con cen tra-25 tion s w ere no t statistically sign if ican t in these sub jec ts .15 T o p u t th e resu lts o f the curren t s tu dy in to perspec tiv e , tw o

issues m u st b e addressed . T h e f irs t is a pragm atic one , and50 in v o lv es the pub licatio ns o f R abas t e t al (1 1 ), w h o reported th at

o bese ind iv iduals lo st m o re w e ig h t consum ing d ie ts low in150 carbo hy drate , and that a sim p le decrease in d ie tary f at in tak e50 can lead to w e igh t lo ss. T here are tw o cruc ial d if f e rences

5 betw een our resu lts and those o f R abast e t al. First, and prob-ab ly m o st im p ortan t, the curren t s tud ie s w ere p erf o rm ed on

10 0 inpatien ts, no t ou tpatien ts. S eco nd , sub jec ts in our stud y also150 partic ip ated in prog ram s o f phy sical ex ercise and b o th behav -60 io ral and nu tritional education . C o nsequ en tly , w e be liev e that

10 0 th e re su lts o f o ur s tudy em phasiz e issues o f energ y in tak e ando u tpu t, and are le ss d ep enden t on v ariations in deg ree o f

180 d ie tary com p liance .A second im portan t issue to address is the ev id en ce that the100 th erm ic e f f ect o f carbohy drate (8% ) is h igh er than that o f fat150 (4% ) (26 ) . A s a con sequ en ce o f these co nsiderations , it has60 been sugges ted th at the h igh er the ratio o f carb ohy drate to f at,5 th e le ss the tendency to gain w e igh t (2 7). O n the o the r hand, the

re lev ance o f th is in f o rm ation to the e f f ec t o f low -energy d ie ts1 g m us t be ques tion ed . Fo r ex am p le, w hen d ie ts con tain ing 4 .21 M J are ing es ted , th e th erm ic e f f ect o f 45% of carbo hy drate is

150 J, com pared w ith a therm ic e f f ect o f 50 J assoc iated w ithea ting 1 5% carboh y drate , ie , a 100 -i d if f e rence per day . T hus,it is theoretically u n lik ely that increasing the re lativ e propor-tion o f carbohy drate to f at in hy poenerge tic d ie ts w ill h av e as ign if ican t e f f ec t on th e w e ig h t lo ss that ensues in com p lian tpatients.

T ABL E 4B ody com pos ition b ef o re and af te r w eigh t lo ss

15% C arbohy drate 4 5% Carboh y drateB e f o re A f te r B e f o re A f ter

To ta l body w e igh t (k g)W eig h t lo ss (% )Body f at ( kg)Fat lo ss (% )W aist circum fe ren ce (cm )Hipc ircumference (cm)W ais t -to -h ip ratio

10 7 5-

47 3-

1 15 41264

0.91 0.02

99 428. 3 0 . 538 22

1 7 . 7 1. 010 4 321 1 7 3 2

0.88 0 .0 l

10 2 4-

41 2-

1 13 31 2 1 20 .93 0.02

95 327 . 4 0. 63 4 22

16 .8 1. 210 3 321 1 2 2 2

0.91 0.02 i S EM .2-- I S ign if icantly dif f erent f rom b e fore w eigh t loss: 2 p < 0.001, - P < 0 .0 1 , p < 0.05.

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W E IGH T LO SS W ITH LOW - OR H IGH -CARBOHYDRATE D IET S 17 7T A B L E 5B io ch em ical in dex es be fore and after w e igh t lo ss

15 % Carb ohydrate 4 5% C arbohydra teB efo re A fte r B efo re A fte r

P lasm a g lucose (mm o lIL ) 5 .3 0 .2 4 .4 0 .1 2 5 .4 0 .3 5 .0 0 .2 P lasm a insu lin (pm o l/L ) 106 .8 15 .6 5 7 .6 6 .6 2 9 6 .0 13 .2 88 .2 9 .6P la sm a c ho le st er ol (m m o l/L ) 5 .7 0 .3 4 .5 0.2 2 6. 1 0 .4 5 .3 0 .3?P lasm a H DL cho les te ro l (m moL fL ) 1. 1 0.1 0 .9 0 .1 2 1 1 0.1 1 .0 0 .lP lasm a triacy lg lyc ero l (m m o lIL ) 1 .7 0 .1 1 .4 0 .l 2 .2 0 .2 1 .8 0.2

SEM .2- 4 S ig nificantly differen t from be fo re w eig ht loss : 2 p < 0 .00 1 , p < 0 .01 , p < o .os .

In co nc lusion , o ur resu lts em phas ize tha t sub stan tialw e igh t loss can occur w hen sub jec ts consum e low -energyd ie ts as in pa tien ts , and tha t th is e ffec t, a s show n by A lfo rde t a l (12) , is in dependen t o f the re la tiv e proportion of d ie ta ryfa t and carbo hydra te . Indeed , if any th ing , consum ption ofthe k ind of low -fa t, h igh-ca rbo hydra te d ie ts fo r w eigh tm ain tenance advoca ted by the N ation al C ho les te ro l E duca-tion P rog ram (28 ) seem s to m in im ize the fa ll in p lasm ainsu lin and triacy lg lycero l con cen trations . T h is is m ostlike ly re la ted to prev io us resu lts show ing tha t bo th p lasm ainsu lin and triacy lg lycero l co ncen tra tion s inc rease in pro -po rtio n to d ie ta ry carbo hyd ra te con sum ption (29 ). In add i-tion , th e H D L -cho leste ro l co ncen tra tion has been show n tod ecrease s ig n ifican tly in w om en consum ing a low -energy ,low -fa t, h igh-ca rboh ydra te d ie t (30) . G iven th e cu rren t ob -se rv ation tha t w eigh t loss w as sim ila r w h en obese su b jectsa te low -en ergy d ie ts, irresp ective of the pro portion of fa tand carboh ydra te in these d ie ts, and th e fac t tha t low -energyd ie ts tha t a re low in fa t and h igh in carb ohydrate lead tosm alle r chang es in insu lin and lip id m etab o lism com paredw ith low -carboh ydra te d ie ts , it seem s reasonab le to questionthe advo cacy of th is d ie ta ry approach . A ltho ugh it is o ftensu ggested tha t low -fat d ie ts w ill have a b ette r long-te rmbenefit w ith a w eig h t-m ain ten an ce d iet, w e are unaw are ofpersuasive da ta in sup port o f th is v iew w ith a w eigh t-lossd ie t. U n til su ch in fo rm ation becom es av ailab le , it seem sreason ab le to su ggest tha t it is energy in take , n o t energycom pos itio n , tha t d e te rm ines w eigh t loss in response tolow -energy d ie ts. U

W e are g ra te fu l to the m em bers of the d ietary s taf f o f the D epa rtm ent ofM edicine for th eir ass ista nc e, esp ecially T L ehm ann , P R ig o li , C Bu ssie n ,an d I D uffey .

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