RESEARCH ARTICLE

LOW CALORIE HIGH PROTEIN DIET VS LOW CALORIE STANDARD PROTEIN DIET
EFFECT ON INFLAMMATION MARKER IN OBESE AND WEIGHT CYCLING SUBJECT
Adventia Natali Paranoan1, Joan Jutamulia1, Ninik Mudjihartini2, Fiastuti Witjaksono3
1 Master Program in Clinical Nutrition, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.
2 Department of Biochemistry Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
3 Department of Nutrition, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia

Abstract
Background: The objective of the study was to compare the effects of calorie restriction diet between high-
protein (HP) and standard protein (SP) to inflammation marker (hs-CRP) in obese with weight cycling subject.
Methods: This study is an open-randomized clinical trial of weight loss program as a part of a larger study
researching the effect of low calorie high protein diet to body composition, oxidative stress, inflammation
marker and metabolic syndrome in obese with weight cycling. A total of 51 healthy obese men and women age
25 – 49 y.o with history of weight cycling were recruited and randomly assigned to one of the intervention
groups, high protein group and standard protein group. Subjects in HP group were given a daily protein intake
of 25-30% from total daily caloric intake, SP group were prescribed 15-20% protein of total energy intake.
Examination of hs-CRP performed in the beginning and the end of intervention. Intervention maintained by
daily text reminder and weekly counselling.
Results: All variables of baseline characteristics between two groups did not show any statistically significant
difference (P>0.05). Two groups had statistically significant reduction in body weight and body mass index
(BMI), (P<0.001).
Conclusion: Low calorie diet with either HP or SP for 8 weeks significantly reduce body weight and BMI in
healthy obese. Standard protein diet brought reduction of hs-CRP
Keywords: high-protein diet, hs-CRP, obese,weight cycling
Corresponding author: Fiastuti Witjaksono (fiastuti_dr@yahoo.com)

Author roles: Paranoan AN: Formal Analysis, Funding Acquisition, Data Curation, Investigation,
Methodology, Project Administration; Jutamulia J: Writing-Original Draft Preparation, Data Curation,
Investigation, Project Administration; Mudjihartini N: Investigation, Methodology, Resources,
Supervision; Witjaksono F: Conceptualization, Funding Acquisition, Methodology, Supervision

Competing interests: No competing interests were disclosed

Grant information: PITTA grant 2017, DRPM Universitas Indonesia

Introduction effects of high-protein diet to weight, cardiovaskular

The global prevalence of obesity by WHO in 1980
was 5% in male population and 8% in female
population. In 2014 the number was rised to 38% in
men age over 18 and 40% in women. WHO stated in
the South-East Asia regions the prevalence of
overweight population various from 7.6% in male
adults in Bangladesh to 53% female adults in
Maldives.1,2 In Indonesia report by RISKESDAS in
2013 shows prevalence of central obesity increased
from 18,8% in 2007 to 26,6%, and the prevalence for
male >18 years old in the country was 19,7% and
female >18 years old was 32,9%. Jakarta had obesity
prevalence higher than the national rate, 30% for
men and 40% for women.3
Obesity associated with morbidity and mortality of
hypertension, cardiovascular disease, dyslipidemia,
diabetes, sleep apnea, osteoarthritis, and many other
health condition. Obese people are more likely to be
disabled in their later years, and many obese-related
illnesses caused people in productive years lost their
productivity. 4 Attemption to lose weight by
managing dietary intake and increasing physical
activity has been done, but the difficulty in
maintained ones body weight caused a fluctuation in
body weight, called weight cycling.5,6 Study by
Votruba,et al in 2002 reported 57 % of 28 women
(16) regain 19% of the body weight they lost after 1
year follow up. 7
Obesity accompanies by low grade inflammation
wich contribute to chronic disease. Although only
few immune cells found in adipose tissue, weight
gain significantly increases the number and the role
in infammation. C-reactive protein is an abnormal
protein that appears in the blood during
inflammation. Highly specific (hs-CRP) test can
detect lower CRP level (0,2 mg/L) compare to CRP
(N≤5 mg/L).4,8
Previous study on high-protein diet effect to
inflammation marker in obese patient shows non
conclusive results. Leila A, et al in 2011 studied the
risk and hs-CRP in 60 overweight and obese women
for 3 months. The comparison made between high-
protein low calorie diet (protein, carbohydrate, and
fat: 25%, 45%, and 30%) and standard protein low
calorie diet (protein, carbohydrate and fat : 15%,
55%, and 30%), hs-CRP in standard group reduced
(−0.08 ± 0.11%, P = 0.06) more than hs-CRP in
standard protein group (−0.04 ± 0.09%, P = 0.06).9
Another study by Kitabchi et al, whereas they
compared various meabolic marker in high-protein
diet and high-carbohydrate diet for 6 months shows
decreased in inflammation marker (CRP) in high-
protein group more relevant than the other group (-
2,1 vs. -0.8 mg/L, P = 0.0003).10
Methods
Participants
Subjects candidates were obtained from the list of
medical records summary of Jakarta’s civil workers
in 2016. Initial screening for subject recruitment was
men and women age > 20 years old with body mass
index ranged 25 – 35 kg/m2. In this study, weight
cycling was defined by history of weight loss ≥2 kg
and regaining weight into or exceeding its initial
body weight at least twice in last five years. Weight
cycling history was obtained from questionnaire
regarding history of body weight changes. Subjects
were excluded if they had diabetes mellitus which
was identified from history taking and post-prandial
blood glucose, having history of gastrointestinal
tract resection, having hormonal disorders which
was identified from interview, using hormonal
contraception, menopause, and having kidney
function disruption-identified from serum urea and
creatinine levels.
 714 candidates from screening age and BMI

Excluded:
abnormal fasting blood glucose
abnormal serum urea and creatinine
refuse to participate
not weight cycling
on hormonal contraception
history of hyperthyroid disease

Initial participating subjects (n=51)

High-protein diet (n=26) Standard-protein diet (n=25)

Drop out Drop out

Liquid diet for dental procedure Problem with work (n=2)
(n=1) Pregnant (n=1)
Working outside the city (n=2) Loss to follow up (n=4)
Loss to follow up (5)

Subjects completing program

Subjects completing program (n= 18)
(n= 18)
Study design and intervention
Participating subjects were allocated into two groups
through block randomization. All subjects meet the
inclusion criteria were measured for anthropometric
data and instructed to cease all their previous diet
program and requested to continue perform their
daily physical activity.
Subjects then equipped with nutrition consultation,
diet formula, and logbook. HP group given
counseling about weight loss program by applying
low calorie-high protein diet with composition of
25-30% protein, 50-55% carbohydrate, 20-25% fat.
SP group were counseled about low calorie-balanced
composition diet with 15-20% protein, 55-60%
carbohydrate, and 20-30% fat.
Length of this study is 8 weeks, which in these
period subjects were instructed to reduce their daily
calorie intake by 1000 kcal from their previous usual
daily intake with lower limit of 1000 kcal/day.
History of previous daily calorie intake were gained
from food recall interview 24 hours by asking type,
cooking method, and estimation of amount of food
consumed by using household size based on food
photo books issued by Tim Survey Konsumsi
Makanan Individu, Ministry of Health of Indonesia.
During this 8 weeks subjects were to fill logbook
everyday to record their diet. In order to insure
compliance, subjects were followed up by weekly
person-to-person encounter and daily text reminder.
The baseline hs-CRP level taken pre-intervention,
and remeasured for endline after 8 weeks diet
intervention.
Data collection
Dietary data measured with 24 hours food recall,
subject’s physical activity calculated using physical
activity form from FAO/WHO. Height measured
using microtoise, while body weight and BMI
measurement were using 8-electrode method of Bio-
Electrical Impedance Analysis (BIA; SC-330 Tanita,
Tokyo, Japan). The hs-CRP measured in PRODIA
Laboratory using Immunochemmiluminescent
(Immulite 1000) methods.
Statistical analysis
The characteristics of Subjects were analyzed
statistically using independent sample t-test (age and
previous calorie intake), Fisher exacy test (gender
and weight cycling history), and Mann-Whitney test
(weight and Body Mass Index (BMI)). All data
except for body weight in HP group given as mean
wih 95% confidence interval.
Thirty-six subjecs were included for analysis.
Change in body weight and BMI analyzed
statistically using independent sample t-test, while
intragroup pre- and post- mean difference of body
weight and BMI analyzed by Wilcoxon test. The
value of measured hs-CRP analyzed statistically by
Mann-Whitney test. Statistical analysis performed
by SPSS version ??
Results
Characteristics of subjects of high protein (HP)
group and Standard Protein (SP) group are presented
in Table 1. There is no statistically significant
difference found in the subjects’ characteristic. The
HP group’s subjects mean age inconsiderably older
than SP group’s. It also had little more daily calorie
intake. The mean body weight of subject in SP group
slightly heavier than HP group’s.
Body weight, BMI and hs-CRP pre- and post-
intervention given in Table.2. SP and HP group both
shows significant intragroup mean difference in
body weight and BMI pre- and post intervention. SP
group have more reduction in body weight and BMI
compare to HP protein (body weight P: 0.0105, BMI
P: 0.054).
Change of hs-CRP in SP group shows reduction
value of hs-CRP after intervention (-1.8 (-4.6 –
13.3)) whereas HP protein group shows
increased hs-CRP after 8 weeks.
Discussion
Result in this study similar to study by Due A. Et al
where standard protein diet in overweight subject
gives better reduction of hs-CRP than high protein
diet does11.
Adipokines, released by adypocites or macrophages
induced low grade chronic inflammation12 in
overweight and obese people. The insignificant
reduced of hs-CRP despite the loss of body weight
and lower BMI may becaused all the subjects still in
overweight or obese state.
Despite the benefit of higher protein diet in
increasing satiety, on this study the standard protein
composition found provide larger reduction body
weight, and hs-CRP level than high protein group.
The amino acids of protein absorbed then pass into
the liver, whereas the rate of synthesis and
degradation influenced by many factors including
immediate food intake and nutrional status13.
Inflammation and physical inactivity includes in
conditions characterized by accelerated wasting of
lean body mass and the protein intake should enough
to counteract protein catabolism in same condition14.

Conclusion
Although both diet gives benefit in reducing body
weight and BMI in obese people with weight
cycling, in a short term weight loss program a
standard protein of 15-20% decrease inflammation
marker (hs-CRP) more than high-protein diet.
 Table 1 : Subject characteristics

Weight cycling
Study groups Age t Gender F Body composition Food intake (kcal) t
frequencyM
Weight
Male Female BMI (kg/m2)M 2-3 4-5
(kg)M

SP 32.06 +8.7 1(5.5%) 17(94.5%) 77.1 + 7.9 30.04 + 2.5 13(72.3%) 5(27.7%) 1703.3 + 412.3

69.2 (60.8
HP 34.78 +8.7 3(16,7%) 15(83.3%) 29.02 + 3.5 15(83.3%) 3(16,7%) 1820.2 + 445.7
– 98.7)

Values are means ± SD except avalues are medians (min- max)

There were no differences between groups (P>0,05) by t Independent samples t-test, MMann-Whitney test, FFisher’s exact test
BMI = Body Mass Index; SP = Standard protein; HP = High protein.

Table 2 : Changes of Body weight, BMI and hsCRP

Group Weight (kg)t BMI (kg/m2) t hsCRP (mg/dl)

Pre Post Δ Pre Post Δ Pre Post Δ
HP (n=10) 69.2 (60.8 – 64.9 (56.2 – -3.9 + 2.3 27.6 + 3.3
29 + 3.5 -1.4 + 0.8 2.1 (0.2 – 13.4) 2.6 (0.1 – 15.5) 0.2 + 2.39
98.7) 95.6)
SP (n=13) 77.1 + 7.9 71.9 + 9.2 -5.2 + 2.4 30 + 2.5 28.0 + 3.1 6.4 + 4.4 4.2 (0.4 – 20 -1.8 (-4.6 –
-2.0 + 1
13.3)
*significance was set at <0.05
tIndependent samples t-test
mMann-Whitney test
pPaired-samples t-test
wWilcoxon test
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