|Year : 2020 | Volume
| Issue : 2 | Page : 63-69
Effect of Fasting Therapy and Low-Calorie Diet on Anthropometric and Serum Lipids in Obese Females
Thittamarnahalli Muguregowda Honnegowda1, Prashant Shetty2, HC Shashikiran3, NS Nandeesh4, PG Arun4, Joysna Thayyil5
1 Centre of Excellence, Government of India, SDM College of Naturopathy and Yogic Sciences, Dakshina Kannada, Karnataka, India
2 Department of Natural Therapeutics, SDM College of Naturopathy and Yogic Sciences, Dakshina Kannada, Karnataka, India
3 Department of Naturopathy and Nutrition, SDM College of Naturopathy and Yogic Sciences, Dakshina Kannada, Karnataka, India
4 Department of Yoga, SDM College of Naturopathy and Yogic Sciences, Dakshina Kannada, Karnataka, India
5 Department of Microbiology, SDM College of Naturopathy and Yogic Sciences, Dakshina Kannada, Karnataka, India
|Date of Submission||22-Jun-2019|
|Date of Decision||12-Jul-2019|
|Date of Acceptance||07-Dec-2019|
|Date of Web Publication||12-Jan-2021|
Dr. Thittamarnahalli Muguregowda Honnegowda
Centre of Excellence, Government of India, SDM College of Naturopathy and Yogic Sciences, Dakshina Kannada, Ujir, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Preclinical and clinical studies have shown the importance of calorie restriction diet in weight reduction and cardiovascular risk factors. In this study, our objective is to compare the naturopathic-based short-term fasting therapy with low-calorie diet (LCD) on anthropometric and lipid profile among obese and overweight persons. A total number of subjects (n = 100) with body mass index (BMI) ≥25 were randomly allocated into either fasting therapy intervention (n = 48) or a LCD (n = 52). Materials and Methods: Participants underwent very LCD (288–904 kcal) in fasting therapy and a LCD (1234 kcal) in the other group respectively for 10 days. Individuals in both the groups were assessed with anthropometric parameters such as BMI, weight, waist circumference, hip circumference and waist-hip ratio, serum lipid profile, and serum leptin levels at the baseline and after 10 days. Results: The anthropometric measurements were decreased significantly in the fasting group when compared with the LCD group (P < 0.05). The decrease in mean serum total cholesterol (TC) (−27.43%), triglycerides (TGs) (−13.05%), and low-density lipoprotein (LDL) (−20.9%) in the treated group were statistically significant (P < 0.001), whereas serum high density lipoprotein (2.32%) was increased but insignificantly (P > 0.001) when compared with the nontreated group. Conclusions: Our findings support that short-term fasting therapy is beneficial in anthropometric measures and reducing leptin level among obese or overweight person compared to LCD. However, long-term adherence of weight loss with these interventions should be tested in future studies with bigger sample size.
Keywords: Fasting therapy, low calorie diet anthropometry, low-calorie diet, naturopathy, serum lipid level
|How to cite this article:|
Honnegowda TM, Shetty P, Shashikiran H C, Nandeesh N S, Arun P G, Thayyil J. Effect of Fasting Therapy and Low-Calorie Diet on Anthropometric and Serum Lipids in Obese Females. J Diabetes Endocr Pract 2020;3:63-9
|How to cite this URL:|
Honnegowda TM, Shetty P, Shashikiran H C, Nandeesh N S, Arun P G, Thayyil J. Effect of Fasting Therapy and Low-Calorie Diet on Anthropometric and Serum Lipids in Obese Females. J Diabetes Endocr Pract [serial online] 2020 [cited 2021 Apr 16];3:63-9. Available from: https://www.jdeponline.com/text.asp?2020/3/2/63/306763
| Introduction|| |
The prevalence of overweight and obesity is increasing worldwide, amplifying concerns over the health risks associated with this worsening problem. In India, a recent ICMR-INDIAB study conducted in three states, namely Tamil Nadu, Maharashtra, and Jharkhand and one Union Territory Chandigarh found that the prevalence of generalized obesity ranged from 11.8% to 33.6% among the residents.
The age-standardized prevalence of generalized obesity in South India was 46% (women: 47%; men: 43%). Abdominal obesity was found in 47%–51% with higher rates in women (women: 56%; men: 35%). Development and urbanization bring with them several habits such as physical inactivity, transport facilities (reduced walking or cycling), fast food, and excessive intake of a high-calorie diet,, all of which have contributed to the emergence of obesity and overweight.
Elevated levels of total and low density lipoprotein (LDL) cholesterol and low levels of high density lipoprotein (HDL) cholesterol are important risk factors for coronary heart disease. Mean total cholesterol (TC) and triglycerides (TGs) concentrations were higher in obese persons in comparison to normal weight. The conventional system of medicine has been useful in managing weight; however, it comes with many side effects.,, Due to this, people have been drifting to complementary and alternative systems of medicine to find a solution for this problem. Among the naturopathy and yoga treatment modalities, therapeutic fasting therapy, raw diet therapy, and a naturopathic based low-calorie diet (LCD) have been practiced by Indian and Western naturopaths.,,, Few studies suggest low and a very LCD (VLCD) are effective in weight reduction in obese and overweight individuals.,
Short-term water fasting therapy is beneficial in healthy individuals to reduce leptin levels and body weight. LCDs involve a reduction in daily caloric intake by 25%–30%. LCDs should be individualized depending on the patient's energy requirements, the severity of the obesity, and any accompanying diseases and treatments. Intermittent fasting (IF) involves caloric restriction for one or several days a week, or every day as the prolongation of the overnight fast., The results from this study have shown that LCDs and IF in patients with can lead to a reduction in body fat mass and metabolic parameter improvements. These beneficial effects arise not only from the loss of body mass, but also from the activation of metabolic pathways specific to fasting conditions.
In another study, a week juice fasting showed health improvement in 78% of in-patients. In addition, fasting was well-tolerated and no serious adverse effects were reported. Although there are studies on the beneficial effects of naturopathic-based fasting therapy on weight reduction in healthy volunteers, there is a paucity of large-scale randomized controlled trials (RCTs) makes it difficult to prescribe fasting with LCDs or LCD as reliable, routine methods for successful and stable weight loss. Therefore in the present study was conducted to see the effects of naturopathic-based fasting therapy against a LCD therapy, on anthropometric measurements and serum lipid levels among obese female individuals and we hypothesized that 10 days' naturopathy fasting therapy would result in significant changes in study parameters than the LCD.
| Materials and Methods|| |
Obese or overweight individuals who volunteered to participate were recruited through e-mail, campus newspaper advertisements, flyers, and word of mouth in the southern district of Karnataka and were screened. The individuals who expressed interest to take part in the study underwent a medical examination with a detailed case history using a structured format after the basic screening. Individuals who have been diagnosed with a body mass index (BMI) ≥25 kg/m2 as per the criteria of World Health Organization, aged between 18 and 40 years, individuals given a written informed consent, fasting naïve for at least past 6 months, and individuals who were not on any hormonal medications for the past 2 months were included in the study. Individuals with morbid obesity and associated comorbid conditions such as drug-induced obesity (e.g., corticosteroid) or endocrine disorders such as hypothyroidism and polycystic ovarian syndrome and other comorbid medical conditions such as uncontrolled hypertension, hypercholesterolemia, type I and II diabetes mellitus, pregnant, and lactating females, were excluded.
Design of the study
This study is a single-centered, single-blinded RCT. The study protocol and informed consent form were reviewed and approved by the Institutional Ethical Committee. The study was registered to Clinical Trials Registry-India-CTRI/2018/02/011978.
Individuals were allocated into either fasting therapy group or naturopathic LCD group by simple randomization by computer-generated randomization table. The randomization was maintained by a naturopathy and yoga medical professional, who were not involved in the individual's recruitment or data collection. Consort 2010 statement is followed to report the RCT as shown in [Figure 1].
Fasting intervention: Naturopathic-based fasting therapy was given to the individuals admitted to the SDM Yoga and Nature Cure Hospital, Ujire, Karnataka. Individuals were kept away from their daily routines so that nothing could interfere with their thoughts and emotions. They had to maintain complete physical and mental rest during the study period with minimal activity. Throughout the intervention period, individuals were under the supervision of a trained naturopathy and yoga physician for 10 days. During juice fasting, the individuals were asked to remain hydrated with approximately 3 L of water per day. No other supplementary diet was given to the individuals. They were taught yogic relaxation techniques such as deep relaxation technique with minimal physical activity (walking). Naturopathic treatments were administered to manage the crisis, if any, during the course of the fasting therapy such as headache, dizziness, vomiting, and diarrhea. Individuals were advised to take enema as a colon cleansing procedure on every day during the fasting period. Daily percentages of different macronutrients with dietary fiber are as follows: naturopathic diet/day (carbohydrates 56.72%, protein 11.47%, fat 7.47%, and fiber 24.34%), raw diet/day (carbohydrates 48.40%, protein 11.13%, fat 9.90%, and fiber 30.57%), lemon juice with honey (lhj)/day (92.93% carbohydrates, protein 2.02%, fat 0%, and fiber 5.05%), and mosambi juice (mj)/day (carbohydrates 83.41%, protein 7.17%, fat 2.69%, and fiber 6.73%). Fasting therapy from 3rd day to 7th day was done with LHJ. LHJ (72 kcal) was taken 4 times a day. Therefore, the total calorie intake was 288 kcal/day. Similarly on the 8th day, fasting was done with MJ (200 kcal) which was taken 4 times a day. Therefore, total calorie intake was 800 kcal/day.
LCD intervention group: The control group underwent a naturopathic LCD (1234 kcal/day) for 10 days which consisted of unseasoned boiled vegetables, chapati, daliya, vegetable/fruit salads, and sprouts. They were also involved in practicing deep relaxation techniques with minimal physical activity. After the intervention period, fasting was administered to subjects in the LCD group who desired to undergo fasting therapy. Details of the diet composition and calories of both the groups are provided in [Table 1].
|Table 1: Detailed food composition of fasting group and low calorie diet group for 10 days|
Click here to view
All the individuals in fasting therapy and naturopathic LCD group were assessed by a naturopathy and yoga physician with the following parameters at the baseline and after 10 days treatment. The outcome assessment was conducted by a doctor who was blind to the study.
Body weight was measured with light clothing and without shoes using a digital weighing machine (Essae, Eeroka ltd) and height was measured using a calibrated stadiometer. BMI was measured using the equation BMI = weight (kg)/height 2 (m2). Waist circumference (WC) was measured midway between the inferior costal margin and the iliac crest using a Gulick Anthropometric tape, U. S. A. The circumference of the hip was measured around the pelvis at the point of maximal protrusion of the buttocks. Finally, the waist to hip ratio (WHR) was measured to assess the body fat distribution.
Assessment of serum lipid profiles and leptin of obese patients
Venous blood (7 ml) was drawn into evacuated, serum separator tubes after 12 h fasting. Complete blood cell count was performed on EDTA-anticoagulated blood using an electronic counter (SE 9000, Sysmex, Kobe, Japan). All lipid profiles were measured with an automatic chemical analyzer (Hitachi 747, Hitachi, Tokyo, Japan) within 4 h after collection. Serum TGs, TC, HDL and LDL concentrations were analyzed by enzymatic colorimetric methods using TG GPO-PAP reagents (Roche Diagnostics GmbH, Mannheim, Germany), SICDIA L T-CHO reagents (Eiken Chemical Industries, Tokyo, Japan), Cholestest-LDL reagents (Daiichi Chemicals, Tokyo, Japan), and Cholestest-HDL reagents (Daiichi Chemicals), respectively.,,, Serum leptin level analyzed with a sandwiched enzyme-linked immunosorbent assay (ELISA) (ELX 800 Absorbance Microplate Reader [BioTek, Winooski, USA] and Assay Max Human Leptin ELISA Kit [Assaypro, St. Charles, MO, USA]).
The distribution of the data was checked for normality using Kolmogorov–Smirnov test. Since the data was not normally distributed nonparametric tests were used. Continuous variables were assessed for the baseline differences between the groups using Mann–Whitney U-test. Wilcoxon signed rank test was done to compare pre- and post-scores within the groups. Changes in serum lipid profile variables due to the diets within each group were tested using Student's paired t-tests. Two-sided P values were considered statistically significant at P < 0.05. Results are expressed as means ± standard deviation unless otherwise indicated. All data were analyzed using SPSS 22 (IBM SPSS Inc., Chicago, IL, USA).
| Results|| |
Of the total 135 obese or overweight persons screened, 100 individuals included into the study after studying inclusion and exclusion criteria and were randomly allocated into either fasting therapy (n = 48) or LCD intervention (n = 52) group to prevent bias baseline characteristics such as weight, age, sex, site-, and race-adjusted. The baseline and 10th day follow-up assessments were available in the 42 individuals each from the both group. Details are delineated in the Consort Flow Chart [Figure 1].
Variables such as sociodemographic and illness characteristics were compared at the baseline in both the groups as shown in the [Table 2].
|Table 2: Detailed food composition of low calorie diet group and first day of fasting group|
Click here to view
Effect of fasting therapy and low calorie diet therapy on obesity/overweight
The difference present within thr groups was performed by using Wilcoxon signed-rank test, which indicates both the groups, did better in all the parameters [Table 3]. However, the greater changes were observed in the fasting group in comparison with the LCD group. Results suggest that there was a significant difference between group with respect to changes in BMI (6.40), weight (−6.04), WC (−3.13), Height circumference (−2.34), and WHR (−2.34) with P < 0.05 [Table 4].
|Table 3: Descriptive statistics of sociodemographic and illness characteristics at the baseline (n=42)|
Click here to view
|Table 4: List of parameters changes in fasting therapy and low-calorie diet group (baseline to 10th day follow up)a|
Click here to view
In this study, 5.24% of weight reduction was observed in the fasting group (mean 3.96) after 10 days of intervention. Furthermore, 2.57% of weight reduction was observed in the naturopathic LCD after 10 days of the intervention. These results indicate greater reductions in weight with short-term fasting therapy. Furthermore, significant (P < 0.005), mean reduction of serum lipid profile) (−27.43%), TGs (−13.05%), and LDL (−20.9%) in the treated group were statistically significant (P < 0.001), whereas serum HDL (2.32%) was increased but insignificantly (P > 0.001) when compared with the nontreated group [Table 5]. Though reduction of serum leptin levels in fasting group is high (47.1%) than to compared LCD (24.12%) but results were insignificant.
| Discussion|| |
The primary goal of obesity management in the primary health care is to lose 5%–15% of the initial body weight. Our results suggest that changes in BMI, weight, hip circumference, WC and WHR were significantly different in the two groups (fasting and LCD), except for serum leptin and results comparison within-group showed that significant reduction in the study parameters in both groups; however, greater changes were observed in the fasting group than compared to LCD group.
Weight reduction of 5.24% obtained in this study is consistent with the previous studies. Fasting for 14 days with fermented medicinal herbs and carbohydrates (400–600 kcal/day) resulted in Mean 5.16 weight loss among 26 subjects. Another study reported that the traditional dietary approach to weight reduction brings about greater weight loss with 600 kcal/day diet in comparison with a LCD (1200 kcal/day).
A recent meta-analysis reported more weight loss with low carbohydrate diet (mean 8.73 kg) at 6 months and 7.25 kg at 12 months, whereas the reduction in weight loss in low-fat diet was 7.99 kg at 6 months and 7.27 kg at a 12 month follow-up. Long-term studies showed 3 times more weight loss amongst subjects who consumed low-fat and fibre-rich foods in comparison to low-fat food consumption alone (−3.4 kg vs. −1.0 kg). In the present LCD study group, weight reduction of 2.57% observed which is consistent with the results of previous studies.
Wood concluded that weight loss induced by carbohydrate restriction favourably alters the secretion of plasma LDL cholesterol and TGs, significantly reduced by 8.9 and 38.6%, respectively. In contrast, plasma HDL cholesterol concentrations were increased by 12%. In addition, they were associated with decreased risk for atherosclerosis and coronary heart disease. It has been suggested that low-carbohydrate high-protein diets and their potential impact on the practice of cardiology, it is clear that people who consume such diets have a reduced intake of calories, resulting in a predictable degree of weight loss. These diets induce a moderate level of ketosis have been shown to improve the lipid profile overall.
In addition VLCD program enabled obese patients to lose an average weight of 35.1 kg in 26 weeks. These weight losses were accompanied by clinically significant decreases in obesity-related risk factors, including a 15% reduction in serum TC and 17% reduction in LDL cholesterol. Results from our study shown that significant reduction in serum lipid profile TC (27.43%), TG (13.05%), LDL (20.9%) with (P < 0.001), whereas, reduction of serum HDL was (2.32%) which is insignificant [Table 5].
A study showed a significant change in serum leptin levels with short-term fasting for 52 h, in this study; leptin mean reduction was from 31 to 12 ng/ml (61.3%) in obese individuals and from 11 to 4 ng/ml (63.64%) in normal weight individuals. The results suggest a reduction in leptin levels were related to regulatory factors other than changes in body fat mass. Furthermore, another study showed 20% reduction in serum leptin levels after a 24 h fasting in obese individuals along with a reduction in BMI. In our study, reduction of leptin levels was observed in both the fasting group and naturopathic LCD group, but no difference was observed between the groups. Percentage of reduction of leptin levels in fasting group (47%) and LCD group (24.12%).
Possible mechanisms behind these changes in weight loss and other anthropometric measurements in both fasting therapy and LCD were as follows. Lemon juice used in fasting and naturopathic diet group is enriched with Vitamin C. Lemon juice with honey has showed to be beneficial by reducing BMI and weight in healthy subjects. Interestingly, Vitamin C levels are inversely related to the body mass indicating obese individuals oxidize 30% more fat during a moderate exercise regimen than individuals with Vitamin C deficiency. Increased intake of whole grains, fruits, and vegetables are beneficial in obesity because whole grains and vegetables have low glycemic index and fruits contain more fiber, anti-oxidant, phytochemicals, and minerals. Likewise, low fat and high fiber diet consumption enhances satiety and reduces hunger. The presence of undigested carbohydrates in whole grains gives bulk to the fecal matter and reduces the intestinal transit time, thereby reducing the risk of weight gain. Furthermore, consumption of a minimum 48 g of whole grains/day is beneficial in weight maintenance (less weight gain from 8 to 13 years) and vascular disease prevention., Short term fasting for 10 days is more beneficial and does not result in any adverse effects because fasting process does not affect the vital organs. Furthermore, there is an increased beta-oxidation observed during fasting. VLCD (450–800 kcal/day) has many advantages such as rapid weight loss, which acts as a motivating factor for obese persons and also the mild ketosis formation suppresses the hunger and slows down the protein loss. Furthermore, VLCD should be used for <16 weeks because of the adverse effects related to ketosis formation. Breaking the fast is considered equally important in Naturopathic philosophy and practice. It was done with Mosambi (sweet lime) juice consumption for a day as it is thicker, having more fiber content so that the individual's system could be prepared for the subsequent return to raw diet followed by a boiled diet.
| Conclusions|| |
The present study shows that the effects of two types of treatment and weight loss due to change of fasting with VLCD were additive: the total effect of slimming on reducing serum levels of TC, LDL cholesterol, and TGs could be ascribed for more than 50% to weight loss per se In conclusion, our findings support beneficial effects of a fasting with VLCD over LCD on obese subjects. The considerable additive effects of weight loss per se underscore the importance of establishing successful dietary treatment and weight maintenance programs for obesity. However, long-term practice and its effect with respect to weight loss adherence and prevention of overweight or obesity with these interventions should be tested in future with robust studies.
Limitations of the study
Follow-up was not done after 10 days of intervention and absence of an active control arm were the main limitations of the study. Although VLCD is beneficial in the short-term reduction of weight, the risk of weight gain is more in this due to binge eating, In addition, body loses large volume of water and also muscle mass for some extent. Once the obese or overweight persons are back on a regular diet, the percentage of weight loss is smaller. Therefore, future directions should focus on long-term sustained adherence of these different types of diets on weight loss.
The authors acknowledge the Central Council for Research in Yoga and Naturopathy, Ministry of AYUSH, Govt of India, New Delhi, for the financial support for the study and for their valuable suggestions and scientific inputs.
Financial support and sponsorship
Funding from the Ministry of AYUSH through Central Council for Research in Yoga and Naturopathy (CCRYN), Government of India, as part of a grant (Z 28015/74/2013-HPC (EMR) – AYUSH-B).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pradeepa R, Anjana RM, Joshi SR, Bhansali A, Deepa M, Joshi PP, et al
. Prevalence of generalized and abdominal obesity in urban and rural India-the ICMR-INDIAB Study (Phase-I) [ICMR-NDIAB-3]. Indian J Med Res 2015;142:139-50.
] [Full text]
Kumar V, Cotran R, Robbins S. Basic Pathology 8th
ed. Jakarta: EGC; 2007.
Seabra A, Mendonça D, Maia J, Welk G, Brustad R, Fonseca AM, et al
. Gender, weight status and socioeconomic differences in psychosocial correlates of physical activity in schoolchildren. J Sci Med Sport 2013;16:320-6.
Szczygielska A, Widomska S, Jaraszkiewicz M, Knera P, Muc K. Blood lipids profile in obese or overweight patients. Ann Univ Mariae Curie Sklodowska Med 2003;58:343-9.
Rucker D, Padwal R, Li SK, Curioni C, Lau DC. Long term pharmacotherapy for obesity and overweight: Updated meta-analysis. BMJ 2007;335:1194-9.
Wolfe SM. When EMA and FDA decisions conflict: differences in patients or in regulation? BMJ 2013;347:f5140.
Wood S. Diet Drug Orlistat Linked to Kidney, Pancreas Injuries. Medscape Medscape News Retrieved; 2011. p. 26.
Gala DR. Efficacy of Fasting. Mumbai: Navneet Publications; 2000.
Herbert Shelton M. The Science and fine Art of Fasting. 5th
Revised edition. Chicago: Natural Hygiene; 1978.
Lindlahr H. Nature Cure: Philosophy and Practice Based on the Unity of Disease and Cure. Chicago: The Nature Cure Publishing Company; 1922.
Rao V. Panchatantra. 5th
ed. India: Prakruthi Prakshya; 1979.
Tsai AG, Wadden TA. The evolution of very-low-calorie diets: An update and meta-analysis. Obesity (Silver Spring) 2006;14:1283-93.
Montesi L, El Ghoch M, Brodosi L, Calugi S, Marchesini G, Dalle Grave R. Long-term weight loss maintenance for obesity: A multidisciplinary approach. Diabetes Metab Syndr Obes 2016;9:37-46.
Chan JL, Williams CJ, Raciti P, Blakeman J, Kelesidis T, Kelesidis I, et al
. Leptin does not mediate short-term fasting-induced changes in growth hormone pulsatility but increases IGF-I in leptin deficiency states. J Clin Endocrinol Metab 2008;93:2819-27.
Ganesan K, Habboush Y, Sultan S. Intermittent Fasting: The Choice for a Healthier Lifestyle. Cureus 2018;10:e2947.
Maurer S. Weight management in primary care. Visc Med 2016;32:342-6.
Beer AM, Ismar LE, Wessely DK, Pötschke T, Weidner B, Wiebelitz KR. Retrospective long-term comparison of naturopathic fasting therapy and weight reduction diet in overweight patients. Evid Based Complement Alternat Med 2014;2014:453407. doi:10.1155/2014/453407.
Kim KW, Song MY, Chung SH, Chung WS. Effect of modified fasting therapy on body weight, fat and muscle mass, and blood chemistry in patients with obesity. J Tradit Chin Med 2016;36:57-62.
Frost G, Masters K, King C, Kelly M, Hasan U, Heavens P, et al
. A new method of energy prescription to improve weight loss. J Hum Nutr Diet 2007;20:152-6.
Johnston BC, Kanters S, Bandayrel K, Wu P, Naji F, Siemieniuk RA, et al
. Comparison of weight loss among named diet programs in overweight and obese adults: A meta-analysis. JAMA 2014;312:923-33.
Shetty P, Mooventhan A, Nagendra HR. Does short-term lemon honey juice fasting have effect on lipid profile and body composition in healthy individuals? J Ayurveda Integr Med 2016;7:11-3.
Haluzík M, Matoulek M, Svacina S, Hilgertová J, Haas T. The influence of short-term fasting on serum leptin levels, and selected hormonal and metabolic parameters in morbidly obese and lean females. Endocr Res 2001;27:251-60.
Johnston CS, Corte C, Swan PD. Marginal Vitamin C status is associated with reduced fat oxidation during submaximal exercise in young adults. Nutr Metab (Lond) 2006;3:35.
Hu FB. Obesity Epidemiology [English]. New York: Oxford University Press; 2008.
Slavin J. Why whole grains are protective: Biological mechanisms. Proc Nutr Soc 2003;62:129-34.
Issa CM. Vitamin D and Type 2 Diabetes Mellitus. Adv Exp Med Biol 2017;996:193-205.
Ye EQ, Chacko SA, Chou EL, Kugizaki M, Liu S. Greater whole-grain intake is associated with lower risk of type 2 diabetes, cardiovascular disease, and weight gain. J Nutr 2012;142:1304-13.
Finnell JS, Saul BC, Goldhamer AC, Myers TR. Is fasting safe? A chart review of adverse events during medically supervised, water-only fasting. BMC Complement Altern Med 2018;18:67.
Browning JD, Baxter J, Satapati S, Burgess SC. The effect of short-term fasting on liver and skeletal muscle lipid, glucose, and energy metabolism in healthy women and men. J Lipid Res 2012;53:577-86.
Delbridge E, Proietto J. State of the science: VLED (Very Low Energy Diet) for obesity. Asia Pac J Clin Nutr 2006;15 Suppl: 49-54.
Fock KM, Khoo J. Diet and exercise in management of obesity and overweight. J Gastroenterol Hepatol 2013;28 Suppl 4:59-63.
Kramer A, Gollhofer A, Armbrecht G, Felsenberg D, Gruber M. How to prevent the detrimental effects of two months of bed-rest mscle, bone and cardiovascular system: An RCT Sci Rep 2017;7;13177. doi: 10.1038/s41598-017-13659-8.
Wadden TA, Foster GD, Sarwer DB, Anderson DA, Gladis M, Sanderson RS, et al
. Dieting and the development of eating disorders in obese women: Results of a randomized controlled trial. Am J Clin Nutr 2004;80:560-8.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]