Original Paper

Received: March 10, 2013

Accepted after revision: August 8, 2013
Published online: September 10, 2013

Ann Nutr Metab 2013;63:159167

DOI: 10.1159/000354868

Comparative Effects of Carbohydrate versus Fat

Restriction on Serum Levels of Adipocytokines,
Markers of Inflammation, and Endothelial Function
among Women with the Metabolic Syndrome:
ARandomized Cross-Over Clinical Trial
SomayehRajaie a,b LeilaAzadbakht a,b ParvanehSaneei a,b MajidKhazaei c
AhmadEsmaillzadeh a,b

a
c

Food Security Research Center, b Department of Community Nutrition, School of Nutrition and Food Science, and
Department of Physiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran

Key Words
Moderate carbohydrate restriction Metabolic syndrome
Inflammation C-reactive protein Adipocytokines
Endothelial function

Abstract
Background and Aims: Despite the efficacy of low-carbohydrate diets in the management of metabolic syndrome
(MetS), it remains unknown if these favorable effects are mediated through changes in inflammation and endothelial
dysfunction. We aimed to assess the effects of moderate
substitution of dietary fats for carbohydrates on serum levels
of adipocytokines, inflammatory indices, and biomarkers of
endothelial function among women with the MetS. Methods: In a randomized cross-over clinical trial, 30 overweight
or obese (BMI >25) women with the MetS were randomly allocated to follow either a high-carbohydrate (HC) (6065%
carbohydrates, 2025% fats) diet or a moderately restricted
carbohydrate (MRC) (4347% carbohydrate, 3640% fats)
diet, each for 6 weeks. After a 2-week washout period, individuals were switched to the alternate diet for an additional
6 weeks. In a fasted state, markers of inflammation [highsensitivity C-reactive protein (hs-CRP), high-sensitivity inter-

2013 S. Karger AG, Basel

02506807/13/06320159$38.00/0
E-Mail karger@karger.com
www.karger.com/anm

leukin-6 (hs-IL-6), high-sensitivity tumor necrosis factor-

(hs-TNF-), and serum amyloid A (SAA)], endothelial function [E-selectin, serum intercellular adhesion molecule 1
(sICAM-1), and serum vascular cell adhesion molecule 1
(sVCAM-1)], and adipocytokines (leptin and adiponectin)
were measured in both study arms at baseline and after
6weeks. Results: Consumption of an HC diet was associated
with increased levels of SAA (3.27 1.22 g/ml) and decreased levels of adiponectin (1.68 2.30 ng/ml), while consumption of an MRC diet did not result in such unfavorable
effects. Serum concentrations of leptin were reduced by the
HC diet (p= 0.02), while they were not affected by the MRC
diet. Changes in serum leptin levels were not significant between the two diets (p = 0.09). Serum concentrations of hsCRP, hs-TNF-, and IL-6 were not influenced by either diet.
No significant differences between the two diets were found
in terms of their effect on sICAM-1 and sVCAM-1 concentrations. Adherence to both diets resulted in a 9 ng/ml decrease
in serum E-selectin levels (p < 0.05 for both). Conclusions:
Partial replacement of dietary carbohydrates by unsaturated
fats prevents the increased levels of markers of systemic inflammation among women with the MetS.
Copyright 2013 S. Karger AG, Basel

Ahmad Esmaillzadeh, PhD

Department of Community Nutrition, School of Nutrition and Food Science
Isfahan University of Medical Sciences
PO Box 81745, Isfahan (Iran)
E-Mail esmaillzadeh@hlth.mui.ac.ir

Introduction

The growing prevalence of metabolic syndrome (MetS)

[1] and its contribution to other chronic inflammatory
diseases such as cardiovascular disease, diabetes, and hypertension [2] have attracted considerable attention in recent years. In the USA 34% of adults are affected by this
syndrome [3]. The prevalence in Iran is comparable to
that in the USA, such that 35% of adults [4] and 10% of
adolescents [5] are affected. Moreover, comparing women worldwide, Iranians have the highest prevalence of this
syndrome [6].
Inflammation plays a pivotal role in the initiation and
progression of several debilitating chronic diseases, most
notably atherosclerosis and type II diabetes [7]. Inflammatory biomarkers have been reported as independent
predictors of future coronary events in both healthy and
unhealthy subjects [8]. Elevated serum levels of inflammatory biomarkers have been suggested as possible contributors to the MetS [9]. Additionally, it has been demonstrated that most of these biomarkers have the potential to increase the expression of factors interfering with
normal insulin signal transduction [10]. Insulin resistance has been proposed as the major underlying mechanism for MetS [11].
The optimal diet for individuals with the syndrome
remains to be explored. Carbohydrate restriction has
been demonstrated to favorably influence features of the
MetS [1113]. Consumption of low-carbohydrate diets,
compared to low-fat diets, has resulted in a better management of insulin resistance and all traditional MetS
components [1113]. However, it remains unknown
whether these favorable effects are mediated through
changes in the inflammatory process and endothelial dysfunction. So far, few studies, with conflicting findings,
have reported the effect of low-carbohydrate diets on proinflammatory cytokines [1416]. Compared to low-fat
diets, consumption of low-carbohydrate diets has been
associated with a greater reduction in circulating inflammatory biomarkers [14]. However, some investigators
have failed to find such a significant effect [15].
Importantly, earlier studies have mostly focused on
strict restriction of dietary carbohydrates [1517]. In other words, most prescribed diets in previous studies were
the same as ketogenic diets, which might be difficult to
consistently adhere to in the long term in apparently
healthy people. This is of particular importance in thirdworld countries where carbohydrates account for >60%
of the total calorie intake [18]. A moderately restricted
dietary carbohydrate intake might be a better choice in
160

Ann Nutr Metab 2013;63:159167

DOI: 10.1159/000354868

these populations for long-term adherence. Furthermore,

previous studies have been performed among healthy
subjects with a normal inflammatory status [1517]. To
better understand the effects of such diets on inflammatory mediators, individuals with the MetS who have lowgrade systemic inflammation are better candidates. We
are aware of only two studies that have evaluated the effects of such diets on inflammation [19, 20]. Both were
performed on healthy subjects and no report is available
among individuals with the MetS. Both studies failed to
find a significant effect, which might be explained by the
normal inflammatory status of the participants [19, 20].
In addition, the majority of previous clinical trials on dietary carbohydrate restriction have used parallel designs
[1416], while the responsiveness of inflammatory biomarkers to dietary interventions and weight loss diets
might be dependent on the genetic background. So, the
cross-over design is more appropriate than a parallel design for such studies. This study aimed to examine the
effects of a moderately restricted dietary carbohydrate intake and its replacement with unsaturated fats on serum
levels of adipocytokines, inflammatory indices, and biomarkers of endothelial function among women with the
MetS.
Subjects and Methods
Subjects
This randomized cross-over clinical trial was carried out
among overweight or obese (BMI >25) women with the MetS as
defined by National Cholesterol Education Program Adult Treatment Panel III criteria [21]. To be enrolled into the study, patients
had to be nonpregnant, nonlactating, and nonsmoking women
aged 2065 years. We included women that had not followed special regimens in the last 3 months. Lack of any evidence of hepatic, renal, thyroid, and gastrointestinal tract diseases as well as diabetes, rheumatoid arthritis, lupus, sever infection, trauma, surgery, and allergy was also a criterion for inclusion. Those taking
medications known to affect weight, appetite, blood pressure, and
inflammation as well as fat/carbohydrate metabolism were not
included in this study. The required sample size for the present
study was calculated using the serum high-sensitivity C-reactive
protein (hs-CRP) level as a key dependent variable [16] in the
standard formula suggested for two-period cross-over studies
[22]. Eligible patients were invited to participate in the study by
distribution of flyers. The flyers were also sent to all universityaffiliated out-patient clinics. Assuming a dropout rate of nearly
50%, from among 316 volunteers screened for inclusion criteria,
39 women met the criteria and enrolled into the study. Nine subjects dropped out during the first phase of the study because of
surgery (n = 1), hip fracture (n = 1), pregnancy (n = 1), taking care
of a pregnant daughter (n = 1), taking care of a patient (n = 1),
traveling (n = 1), and other personal reasons (n = 3). These patients did not start the diet therapy (fig.1). Finally, the study was

Rajaie/Azadbakht/Saneei/Khazaei/
Esmaillzadeh

Screened for participation

n = 316

Enrolment of eligible subjects

n = 39

Ineligible subjects according

to inclusion criteria
n = 277

Run-in period
n = 39

HC diet
n = 19

MRC diet
n = 20

Dropouts (n = 5)
Pregnancy (n = 1)

Dropouts (n = 4)
Surgery (n = 1)

Taking care of a pregnant

daughter (n = 1)

Hip fracture (n = 1)
Washout period
n = 30

Traveling (n = 1)

Taking care of a patient

(n = 1)

Personal reasons (n = 2)

Personal reasons (n = 1)

HC diet
n = 16

MRC diet
n = 14

Completed and analyzed

n = 30

Fig. 1. Patient flow diagram.

completed by 30 women. All participants provided written informed consent. The study wasapproved by the ethical committee
of the Isfahan University of Medical Sciences, Isfahan, Iran, and
is registered (IRCT201105131485N3) at the Iranian website for
registration of clinical trials (www.irct.ir).

activity and supplement use throughout the study. Anthropometric and biochemical measurements were done in the fasting state
in both study arms at baseline and after 6 weeks.

Study Design
At baseline, we collected information about demographic characteristics, medical history, and medication/supplement use. Prior
to the dietary intervention, all participants underwent a 2-week
run-in period during which they continued their habitual dietary
intakes and physical activity levels. All subjects were educated on
how to record their dietary intakes and physical activities. Threeday food records (2 weekdays and 1 weekend day) and 2-day physical activity records were taken from each subject throughout this
period. Following the run-in period, participants were randomly
assigned to consume either a high-carbohydrate (HC) diet or a
moderately restricted carbohydrate (MRC) diet (explained below),
according to a random-order cross-over design, for 6-weeks duration each. Treatment assignments were separated by a 2-week
washout period. Dietary and physical activity records were completed by each participant once every 2 weeks during the study.
Subjects were asked not to change their habitual levels of physical

Diets
Since all participants were overweight or obese, both diets were
designed to be calorie restricted (350700 kcal less than the computed energy requirement for each participant). The calorie requirements of each subject were estimated based on resting energy expenditure (using the Harris-Benedict equation) and physical activity
levels. The main difference between the two diets was the percent of
energy from fats and carbohydrates. The macronutrient composition of the HC diet was designed to be similar to that in Iranian
usual diets [18], i.e. 6065% of the energy from carbohydrates and
2025% from fats. The MRC diet was composed of 4347% of total
calories as carbohydrates and 3640% as dietary fats. Indeed, in the
MRC diet 1520% of the energy from carbohydrates was replaced
by nonhydrogenated vegetable oils. The protein content of both diets
was 1517% of the total energy. A 7-day cycle menu was provided
for each participant. To facilitate compliance, subjects were given an
exchange list of food groups and individually instructed about the
goals of each phase as well as the exchange list. Compliance with the
diets was assessed by the investigators by asking subjects to record

Moderate Carbohydrate Restriction and

Inflammation

Ann Nutr Metab 2013;63:159167

DOI: 10.1159/000354868

161

their dietary intakes once every 2 weeks. Dietary records were analyzed for their energy and macronutrient content using NutritionistIV software which was modified for Iranian food items.
Biochemical Assessment
After a 12-hour overnight fast, 10 ml venous blood samples
were collected and immediately centrifuged at 2,500 g for 10 min.
The obtained serum was stored frozen at 70 C until later analysis.
Serum concentrations of inflammatory biomarkers [including hsCRP, high-sensitivity interleukin-6 (hs-IL-6), high-sensitivity tumor necrosis factor- (hs-TNF-), and serum amyloid A (SAA)]
and adipocytokines (leptin and adiponectin), as well as markers of
endothelial function [including E-selectin, serum intercellular adhesion molecule 1 (sICAM-1), and serum vascular cell adhesion
molecule 1 (sVCAM-1)], were quantified by means of an enzymelinked immunosorbent assay using commercially available kits.
Both inter- and intra-assay coefficients of variation for all biomarkers were less than 10%.

Assessment of other Variables

Height and body weight were measured according to standard
protocols and recorded to the nearest 0.5 cm and 100 g, respectively. The body mass index (BMI) was calculated. Waist and hip
circumferences were measured to the nearest 0.5 cm using an unstretched tape measure. Body composition was assessed via the
bioelectrical impedance method (Tanita, Tokyo, Japan). All measurements were taken following an overnight fast, by the same person. Data from the physical activity records were expressed as metabolic equivalent (MET) intensities that were computed considering the type and duration of activities [23]. Other information
about demographic characteristics, the medical history, and medication/supplement use was collected using questionnaires.
Statistical Analysis
We assessed normal distribution of the variables using the Kolmogrov-Smirnov test, histograms, and p-p plots. If needed, the
data were log (ln) transformed to achieve a normal distribution.
Data were analyzed based on the intention-to-treat approach. General characteristics of the study participants were expressed using
descriptive statistics (means, SEMs, and ranges). A paired t test was
used to compare dietary intakes and physical activity METs during
the intervention. For each dependent variable, we computed the
changes from baseline by subtracting the baseline value from the
end-of-trial value. Within- and between-group changes in biochemical markers were compared using a paired samples t test. To
explore if the observed changes could be explained by weight loss,
we controlled the analysis for weight change by using a general linear model. We also assessed whether the carry-over and treatment
effects were significant. All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS), version
16. p < 0.05 was considered statistically significant.

Results

The baseline characteristics of study participants are

presented in table1. The subjects ages ranged from 24 to
57 years. At the time of enrollment, all participants were
162

Ann Nutr Metab 2013;63:159167

DOI: 10.1159/000354868

Table 1. Baseline characteristics of the participants (n = 30)

Age, years
Weight, kg
Height, cm
BMIa, kg/m2
Waist circumference, cm
Hip circumference, cm
Waist-to-hip ratio
Fat mass, kg
Body fat, %
Lean body mass, %
Categorical variables, %
Married
Family history of diabetes
Family history of stroke
Current supplement use
Regular physical activityb
Postmenopause
an

Mean

Standard
deviation

Range

42.4
80.8
157.6
33.0
107.2
116.1
0.91
32.4
39.5
60.5

7.2
14.8
5.6
4.6
15.7
10.3
0.06
8.7
3.9
3.9

2457
55.9104.8
147172
2541.1
88154
100140
0.801.03
18.848.9
30.747.0
53.069.3

96.7
53.3
70.0
33.7
46.7
26.7

= 29.

bHaving

a fixed physical activity program for weekdays.

overweight and centrally obese. Their mean BMI was 33

and their mean waist circumference was 107 cm. On average, the percent of body fat was 39.5%. In total, 70 and
53% of subjects had a family history of stroke and diabetes, respectively.
Figure 2 shows the physical activity scores of participants throughout the study. The subjects mean physical
activity was 37.8 METh/day during the HC diet and 37.2
METh/day during the MRC phase. As expected, the
physical activity levels of participants were constant during the study and differences between the two intervention periods were not significant (p = 0.17).
The dietary intakes of study participants during interventions are summarized in table2. Based on food diaries,
the mean energy intakes during the HC and MRC phases
were not significantly different (1,740 58 vs. 1,730 52
kcal/day, p = 0.84). The percentage of energy from carbohydrates was 58% in the HC phase and 46% in the MRC
phase. Dietary fat made up 28% of the total energy intake
during the HC diet and 40% during the MRC diet. As recommended, the percent of energy obtained from protein
was similar between the two groups. Moderate restriction
of dietary carbohydrates was associated with a lower consumption of grains and fruits as well as lower dietary intakes of fiber, potassium, and folate. In contrast, during
Rajaie/Azadbakht/Saneei/Khazaei/
Esmaillzadeh

Table 2. Dietary intakes of the study participants during interventions (n = 30)

HC dieta
Food groups (servings/day)
Dairy products
Vegetables
Fruits
Grains
Meats and alternatives
Fats and oils
Nutrients
Macronutrients
Energy, kcal
Carbohydrate, %
Protein, %
Fat, %
Micronutrients
Cholesterol, mg
Fiber, g
Calcium, mg
Phosphorus, mg
Sodium, mg
Potassium, mg
Zinc, mg
Folic acid, g
Vitamin B6, mg

MRC dietb

Differencec

pd

1.630.10
3.690.26
5.110.31
9.160.40
2.820.19
5.240.31

1.650.12
3.230.23
3.310.15
7.460.23
3.560.15
9.720.56

0.220.12
0.460.24
1.800.30
1.700.43
0.740.17
4.470.48

0.86
0.07
<0.01
<0.01
<0.01
<0.01

1,740.258.0
57.80.6
15.60.3
27.70.6

1,729.951.6
45.90.7
15.60.3
39.50.8

10.350.2
12.00.9
0.00.4
11.80.9

0.84
<0.01
0.96
<0.01

165.415.8
22.71.2
1,093.555.4
1,156.253.5
1,198.6148.2
3,563.5180.4
7.60.4
335.123.4
1.60.1

163.014.9
18.50.9
1,028.148.5
1,149.545.6
1,046.4115.6
3,114.1113.5
8.00.4
285.714.3
1.60.1

2.414.3
4.21.3
65.450.2
6.748.4
152.298.5
449.4164.2
0.50.5
49.422.1
0.00.1

0.87
<0.01
0.20
0.89
0.13
0.01
0.26
0.03
0.91

All values are means SEM.

aEnergy-restricted diet that contained 6065% of energy from carbohydrates, 2025% from fats, and 1520% from proteins.
b
Energy-restricted diet that contained 4347% of energy from carbohydrates, 3640% from fats, and 1520% from proteins.
cCalculated by subtracting the values of the MRC diet from the values of the HC diet.
dBy paired t test.

Moderate Carbohydrate Restriction and

Inflammation

40

p = 0.17

38
36
MET h/day

the HC phase, participants consumed lower servings of

oils and meats compared with the MRC phase. The mean
dietary intake of dairy and vegetables as well as micronutrients (other than folate and potassium) did not differ
between the two diets.
The effects of both diets on anthropometric measures,
circulating levels of inflammatory indices, and adipocytokines are given in table3. Adherence to HC and MRC
diets for 6 weeks led to a similar reduction in body weight
in both groups (1.70 0.36 and 1.72 0.40 kg, p =
0.96). Serum concentrations of hs-CRP, hs-TNF-, and
hs-IL-6 were not influenced by either diet. Also, we did
not obtain a statistically significant difference when comparing changes between the two diets. Consumption of
an HC diet was associated with increased levels of SAA
and decreased levels of adiponectin, while consumption
of an MRC diet did not result in such unfavorable effects.
Serum concentrations of leptin were reduced by the HC

34

37.8
35.6

36.5

37.2

32
30
28
26
24

Run-in

HC diet

Washout

MRC diet

Fig. 2. Physical activity levels of participants during the study. HC

diet: an energy-restricted diet that contained 6065% of energy

from carbohydrates, 2025% from fats, and 1520% from proteins.
MRC diet: an energy-restricted diet that contained 4347% of energy from carbohydrates, 3640% from fats and 1520% from proteins. The physical activity levels of participants were not different
between groups during the study.

Ann Nutr Metab 2013;63:159167

DOI: 10.1159/000354868

163

Table 3. Effect of an MRC diet on weight, serum levels of inflammatory indices and adipocytokines among women with the MetS

Variables

Weight, kg
BMI, kg/m2
hs-CRP, mg/l
hs-TNF-, ng/ml
hs-IL-6, ng/ml
SAA, g/ml
Leptina, ng/ml
Adiponectina, ng/ml

HC dietb (n = 30)

MRC dietc (n = 30)

pf

baseline

6th week

changed

pe

baseline

6th week

changed

pe

80.914.5
32.25.0
1.381.29
0.211.91
0.151.90
2.611.39
78.35.5
10.60.3

79.214.5
31.55.1
1.151.24
0.461.42
0.042.28
6.621.13
67.26.1
8.90.3

1.700.36
0.670.14
1.090.43
0.132.03
0.050.24
3.271.22
11.144.47
1.682.30

<0.001
<0.001
0.42
0.16
0.21
<0.01
0.02
<0.001

79.714.4
31.75.0
1.401.28
0.182.01
0.102.00
4.011.15
71.05.6
10.30.3

78.013.5
31.34.8
1.081.26
0.511.58
0.161.90
4.571.12
73.34.4
9.80.2

1.720.40
0.960.16
0.290.48
0.102.12
0.110.17
0.200.79
2.685.30
0.462.17

<0.001
<0.001
0.11
0.19
0.70
0.38
0.62
0.25

0.96
0.90
0.24
0.99
0.57
0.04
0.09
0.08

Reported values for baseline and the 6th week are geometric means SEM and those for changes are means SEM.
aReported values are means SEM.
b
Energy-restricted diet that contained 6065% of energy from carbohydrates, 2025% from fats, and 1520% from proteins.
cEnergy-restricted diet that contained 4347% of energy from carbohydrates, 3640% from fats, and 1520% from proteins.
d
Calculated by subtracting values at the 6th week from values at baseline.
e
Within-group changes by paired t test.
fBetween-group changes by paired t test.

Table 4. Effect of an MRC diet on circulating levels of biomarkers of endothelial function among women with the MetS

Variables

HC dieta (n = 30)
baseline

sICAM-1, ng/ml
sVCAM-1, ng/ml
E-selectinf, ng/ml

6th week

MRC dietb (n = 30)

changec

193.75.7
219.38.2 25.609.08
1,159.472.8 1,233.251.9 73.8392.76
24.531.13
18.171.10 8.713.92

pe

pd

baseline

0.01
0.43
0.02

188.75.5
211.78.7
23.009.57 0.02
1,155.480.8 1,302.946.5 147.4783.60 0.09
24.531.10
18.171.08 9.163.87 0.01

6th week

changec

pd
0.87
0.62
0.94

Reported values are means SEM.

aEnergy-restricted diet that contained 6065% of energy from carbohydrates, 2025% from fats, and 1520% from proteins.
b
Energy-restricted diet that contained 4347% of energy from carbohydrates, 3640% from fats, and 1520% from proteins.
c
Calculated by subtracting values at the 6th week from values at baseline.
dWithin-group changes by paired t test.
eBetween-group changes by paired t test.
fReported values for baseline and the 6th week are geometric means SEM.

diet (p = 0.02), while they were not affected by the MRC

diet. Changes in serum leptin levels were not significant
between the two diets (p = 0.09).
The responsiveness of markers of endothelial function
to the HC and MRC diets is shown in table4. Consumption of both HC and MRC diets led to significant rises in
sICAM-1 concentrations of 25.6 and 23 ng/ml, respectively (p = 0.01 and p = 0.02, respectively); however, no
significant differences between the two diets were found
(p = 0.87). Serum sVCAM-1 levels were not significantly
affected by either diet. Adherence to both diets resulted
164

Ann Nutr Metab 2013;63:159167

DOI: 10.1159/000354868

in a 9 ng/ml decrease in serum E-selectin levels (p < 0.05

for both); however, comparing the two diets, no significant difference was found (p = 0.94).

Discussion

The major finding of the present study was that consumption of an MRC diet had more favorable impacts on
SAA and adiponectin concentrations compared to an HC
diet; however, we failed to find a significant effect on othRajaie/Azadbakht/Saneei/Khazaei/
Esmaillzadeh

er inflammatory biomarkers. To the best of our knowledge, this study is the first to examine the effect of moderate variation in the dietary carbohydrate intake on surrogate measures of inflammation in a cross-over design.
Earlier studies have mostly applied parallel designs [14
16]. Moreover, this study was conducted among women
with the MetS. This is of particular importance given that
the MetS is the underlying condition for diabetes and cardiovascular disease [2], particularly in Middle Eastern
countries where the syndrome is highly prevalent with its
unique pattern. Furthermore, unlike most previous studies [1517], we used moderate carbohydrate restriction in
order to increase the possibility of long-term adherence
to carbohydrate-restricted diets. Identical protein contents in both diets is another point of this study.
Low-grade systemic inflammation has been recognized as a potent trigger for the pathogenesis and development of atherosclerosis, diabetes, neurodegenerative
disorders, cardiovascular disease, and MetS [79]. Finding the optimal dietary macronutrient composition to
modulate the inflammatory response would, therefore, be
of great importance. In the current study, we hypothesized that moderate replacement of dietary carbohydrates
by fats would improve circulating markers of inflammation, endothelial function, and adipocytokines. We found
that SAA and adiponectin levels were more significantly
affected by the MRC diet than that by the HC diet. Furthermore, our previous investigation in this population
of women showed a greater improvement in central obesity, atherogenic dyslipidemia, and hypertension with the
MRC diet than that with the HC diet [24]. These findings
are in line with previous studies [14, 25, 26]. In a parallel
randomized clinical trial, Forsythe et al. [14] indicated
that a very-low-carbohydrate diet (12% of energy from
carbohydrate) resulted in a greater reduction in some inflammatory biomarkers compared to a low-fat diet. In another clinical trial among insulin-resistant patients, moderate carbohydrate restriction led to lower serum E-selectin concentrations compared to fat restriction [25].
We found that the changes in most proinflammatory
cytokines and adhesion molecules were not significantly
different between the two diets. In agreement with our
observations, several previous studies have also shown
that carbohydrate restriction, for 2 weeks to 6 months,
leads to similar changes in serum hs-CRP [15, 17, 19, 27,
28], TNF- [17, 20, 28], IL-6 [17, 20, 28], and sICAM-1
[17, 28] levels compared to a low-fat diet. These findings
suggest that the magnitude of weight loss, not dietary
macronutrient composition, should be considered as the
primary determinant of inflammation modulation.

Contrary to our expectations, some inflammatory indices were significantly increased despite weight loss.
Others have also reached such findings [16, 29]. In the
context of weight loss diets, Seshadri et al. [30] showed
that consumption of a very-low-carbohydrate diet for
6months among patients with an initial low to moderate
level of hs-CRP (3 mg/dl) resulted in a significant increase in serum CRP levels [30]. It seems that baseline
levels of serum hs-CRP are a major determinant of the
inflammatory response to weight loss [29, 30]. Increased
levels of inflammation following weight loss have mostly
been reported among those with a normal baseline level
of hs-CRP; however, among individuals with high serum
hs-CRP levels at baseline, weight loss has resulted in reduced levels of inflammatory biomarkers [30]. In the current study, when the data were analyzed based on baseline
serum levels of hs-CRP, we reached the same findings.
Increased inflammation despite significant weight loss in
the current study needs further investigation. It seems
that factors other than weight loss might influence systemic inflammation.
Several underlying mechanisms for the effects of carbohydrates on the surrogate inflammatory biomarkers
have been postulated [3135]. Hyperglycemia and hypertriglyceridemia induced by excessive dietary carbohydrate intake increase oxidative stress via the activation of
enzymes responsible for reactive oxygen species production [31, 32]. A growing body of evidence indicates that
glucose intake activates several proinflammatory transcription factors like nuclear factor (NF)-B, activator
protein 1 (AP-1), and early growth response 1 (Egr-1) and
consequently upregulates the expression of systemic inflammation mediators (such SAA and adiponectin) [33,
34]. Moreover, activation of leukocytes, particularly T
lymphocytes and monocytes, as well as complement systems by triglyceride-rich lipoproteins might be involved
in the pathogenesis of inflammation [35]. Numerous
studies have also hypothesized that the carbohydrate intake might affect inflammation by interfering with the
normal insulin activity [34].
Our findings must be interpreted while considering
some limitations. We used the single measure of proinflammatory status to achieve serum levels of inflammatory biomarkers, while markers of systemic inflammation
fall and rise from day to day. Repeated measurements of
these biomarkers would be required for a better reflection
of inflammation. Furthermore, despite having MetS, just
4 cases were insulin resistant [36] at baseline. Some studies have shown that hypocaloric diets reduce inflammation only in insulin-resistant patients, not in other obese

Moderate Carbohydrate Restriction and

Inflammation

Ann Nutr Metab 2013;63:159167

DOI: 10.1159/000354868

165

subjects [37]. Others have indicated that individuals with

low initial levels of inflammatory biomarkers do not benefit from weight loss interventions [30]. One might believe that a 2-week washout period might preclude us
from finding significant differences between the two diets. It should be noted that the present study was a dietary
intervention, so the effects of these interventions will not
remain for a long time and a 2-week washout period
might be enough to eliminate the effects of the first intervention. Furthermore, several previous studies that have
applied dietary intervention have used a 2-week washout
period [3842]. Moreover, based on the lack of any carryover effect, it can be concluded that a 2-week wash-out
period was enough.
Given the above mentioned limitations, we conclude
that partial replacement of dietary carbohydrates by unsaturated fats prevents the increased levels of markers of
systemic inflammation among women with the MetS.

Further studies, particularly among those with elevated

inflammation, should measure the expression of other
adipokines such as CCLs (CC chemokines ligand) or
CXCLs (CXC chemokine ligand) and the activity of iNOS
(inducible nitric oxide synthase) to explore the plausible
mechanism and confirm our findings.

Acknowledgments
The authors would like to thank the Clinical Research Council of the Isfahan University of Medical Sciences as well as the
Food Security Research Center for their financial support of this
study.

Disclosure Statement
The authors have no personal or financial conflicts of interest.

References
1 Kolovou GD, Anagnostopoulou KK, Salpea
KD, Mikhailidis DP: The prevalence of metabolic syndrome in various populations. Am J
Med Sci 2007;333:362371.
2 Ford ES: Risks for all-cause mortality, cardiovascular disease, and diabetes associated with
the metabolic syndrome: a summary of the
evidence. Diabetes Care 2005;28:17691778.
3 Ford ES, Li C, Zhao G: Prevalence and correlates of metabolic syndrome based on a harmonious definition among adults in the US. J
Diabetes 2010;2:180193.
4 Delavari A, Forouzanfar MH, Alikhani S,
Sharifian A, Kelishadi R: First nationwide
study of the prevalence of the metabolic syndrome and optimal cutoff points of waist circumference in the Middle East: the national
survey of risk factors for noncommunicable
diseases of Iran. Diabetes Care 2009;32:1092
1097.
5 Esmaillzadeh A, Mirmiran P, Azadbakht L,
Etemadi A, Azizi F: High prevalence of the
metabolic syndrome in Iranian adolescents.
Obesity (Silver Spring) 2006;14:377382.
6 Cameron AJ, Shaw JE, Zimmet PZ: The metabolic syndrome: prevalence in worldwide
populations. Endocrinol Metab Clin North
Am 2004;33:351375.
7 Blake GJ, Ridker PM: Inflammatory biomarkers and cardiovascular risk prediction. J
Intern Med 2002;252:283294.
8 Cesari M, Penninx BW, Newman AB,
Kritchevsky SB, Nicklas BJ, Sutton-Tyrrell K,
et al: Inflammatory markers and cardiovascular disease [The Health, Aging and Body Composition (Health ABC) Study]. Am J Cardiol
2003;92:522528.

166

9 Giugliano D, Ceriello A, Esposito K: The effects of diet on inflammation: emphasis on

the metabolic syndrome. J Am Coll Cardiol
2006;48:677685.
10 Schenk S, Saberi M, Olefsky JM: Insulin sensitivity: modulation by nutrients and inflammation. J Clin Invest 2008;118:29923002.
11 Volek JS, Phinney SD, Forsythe CE, Quann
EE, Wood RJ, Puglisi MJ, et al: Carbohydrate
restriction has a more favorable impact on the
metabolic syndrome than a low fat diet. Lipids
2009;44:297309.
12 Muzio F, Mondazzi L, Harris WS, Sommariva
D, Branchi A: Effects of moderate variations
in the macronutrient content of the diet on
cardiovascular disease risk factors in obese
patients with the metabolic syndrome. Am J
Clin Nutr 2007;86:946951.
13 Feinman RD, Volek JS, Westman EC: Dietary
carbohydrate restriction in the treatment of
diabetes and metabolic syndrome. Clin Nutr
Insight 2008;12:15.
14 Forsythe CE, Phinney SD, Fernandez ML,
Quann EE, Wood RJ, Bibus DM, Kraemer
WJ, Feinman RD, Volek JS: Comparison of
low fat and low carbohydrate diets on circulating fatty acid composition and markers of
inflammation. Lipids 2008;43:6577.
15 OBrien KD, Brehm BJ, Seeley RJ, Bean J,
Wener MH, Daniels S, DAlessio DA: Dietinduced weight loss is associated with decreases in plasma serum amyloid A and C-reactive protein independent of dietary macronutrient composition in obese subjects. J Clin
Endocrinol Metab 2005;90:22442249.
16 Rankin JW, Turpyn AD: Low carbohydrate,
high fat diet increases C-reactive protein dur-

Ann Nutr Metab 2013;63:159167

DOI: 10.1159/000354868

17

18

19

20

21

22
23

ing weight loss. J Am Coll Nutr 2007;26:163

169.
Sharman MJ, Volek JS: Weight loss leads to
reductions in inflammatory biomarkers after
a very-low-carbohydrate diet and a low-fat
diet in overweight men. Clin Sci (Lond) 2004;
107:365369.
Kimiagar SM, Ghaffarpour M, Houshiar-Rad
A, Hormozdyari H, Zellipour L: Food consumption pattern in the Islamic Republic of
Iran and its relation to coronary heart disease.
East Mediterr Health J 1998;4:539547.
Koren MS, Purnell JQ, Breen PA, Matthys
CC, Callahan HS, Weigle DS: Plasma C-reactive protein concentration is not affected
by isocaloric dietary fat reduction. Nutrition
2006; 22: 444448.
Hudgins LC, Baday A, Hellerstein MK, Parker TS, Levine DM, Seidman CE, et al: The effect of dietary carbohydrate on genes for fatty
acid synthase and inflammatory cytokines in
adipose tissues from lean and obese subjects.
J Nutr Biochem 2008;19:237245.
Grundy SM, Brewer HB, Cleeman JI, Smith
SC, Lenfant C: Definition of metabolic syndrome: report of the National Heart, Lung,
and Blood Institute/American Heart Association conference on scientific issues related to
definition. Circulation 2004;109:433438.
Fleiss JL: The design and analysis of clinical
experiments. London, Wiley, 1986, pp 263
271.
Ainsworth BE, Haskell WL, Whitt MC, Irwin
ML, Swartz AM, Strath SJ, et al: Compendium
of physical activities: an update of activity
codes and MET intensities. Med Sci Sports
Exerc 2000;32:S498S504.

Rajaie/Azadbakht/Saneei/Khazaei/
Esmaillzadeh

24 Rajaie S, Azadbakht L, Khazaei M, Esmaillzadeh A: Effect of moderately-restricted carbohydrate diet on cardiovascular risk factors
among women with metabolic syndrome. J
Isfahan Med Sch 2012;29:27392755.
25 McLaughlin T, Carter S, Lamendola C, Abbasi F, Yee G, Schaaf P, et al: Effects of moderate variations in macronutrient composition
on weight loss and reduction in cardiovascular disease risk in obese, insulin-resistant
adults. Am J Clin Nutr 2006;84:813821.
26 Seshadri P, Samaha FF, Stern L, Ahima RS,
Daily D, Iqbal N: Adipocytokine changes
caused by low-carbohydrate compared to
conventional diets in obesity. Metab Syndr
Relat Disord 2005;3:6674.
27 Tay J, Brinkworth GD, Noakes M, Keogh J,
Clifton PM: Metabolic effects of weight loss
on a very-low-carbohydrate diet compared
with an isocaloric high-carbohydrate diet in
abdominally obese subjects. J Am Coll Cardiol 2008;51:5967.
28 Al-Sarraj T, Saadi H, Calle MC, Volek JS, Fernandez ML: Carbohydrate restriction, as a
first-line dietary intervention, effectively reduces biomarkers of metabolic syndrome in
Emirati adults. J Nutr 2009;139:16671676.
29 Peairs AT, Rankin JW: Inflammatory response to a high-fat, low-carbohydrate weight
loss diet: effect of antioxidants. Obesity (Silver
Spring) 2008;16:15731578.
30 Seshadri P, Iqbal N, Stern L, Williams M, Chicano KL, Daily DA, et al: A randomized study
comparing the effects of a low-carbohydrate
diet and a conventional diet on lipoprotein
subfractions and C-reactive protein levels in
patients with severe obesity. Am J Med 2004;
117:398405.

Moderate Carbohydrate Restriction and

Inflammation

31 Dandona P, Aljada A, Chaudhuri A, Mohanty

P, Grag R: Metabolic syndrome: a comprehensive perspective based on interactions between obesity, diabetes and inflammation.
Circulation 2005;111:14481454.
32 Mohanty P, Hamouda W, Garg R, Aljada A,
Ghanim H, Dandona P: Glucose challenge
stimulates reactive oxygen species (ROS) generation by leucocytes. J Clin Endocrinol
Metab 2000;85:29702973.
33 Deopurkar R, Ghanim H, Friedman J, Abuaysheh S, Sia CL, Mohanty P, et al: Differential
effects of cream, glucose, and orange juice on
inflammation, endotoxin, and the expression
of Toll-like receptor-4 and suppressor of cytokine signaling-3. Diabetes Care 2010; 33:
991997.
34 Aljada A, Ghanim H, Mohanty P, Syed T,
Bandyopadhyay A, Dandona P: Glucose intake induces an increase in activator protein 1
and early growth response 1 binding activities, in the expression of tissue factor and matrix metalloproteinase in mononuclear cells,
and in plasma tissue factor and matrix metalloproteinase concentrations. Am J Clin Nutr
2004;80:5157.
35 Klop B, Proctor SD, Mamo JC, Botham KM,
Castro Cabezas M: Understanding postprandial inflammation and its relationship to lifestyle behaviour and metabolic diseases. Int J
Vasc Med 2012;2012:947417.

36 Stern SE, Williams K, Ferrannini E, DeFronzo

RA, Bogardus C, Stern MP: Identification of
individuals with insulin resistance using routine clinical measurements. Diabetes 2005;54:
333339.
37 McLaughlin T, Abbasi F, Lamendola C, Liang
L, Reaven G, Schaaf P, Reaven P: Differentiation between obesity and insulin resistance in
the association with C-reactive protein. Circulation 2002;106:29082912.
38 Weaver KL, Ivester P, Seeds M, Case LD,
Arm JP, Chilton FH: Effect of dietary fatty
acids on inflammatory gene expression in
healthy humans. J Biol Chem 2009; 284:
1540015407.
39 Jenkins DJ, Kendall CW, Connelly PW, Jackson CJ, Parker T, Faulkner D, et al: Effects of
high- and low-isoflavone (phytoestrogen) soy
foods on inflammatory biomarkers and proinflammatory cytokines in middle-aged men
and women. Metabolism 2002;51:919924.
40 Lindqvist H, Langkilde AM, Undeland I, Rdendal T, Sandberg AS: Herring (Clupea
harengus) supplemented diet influences risk
factors for CVD in overweight subjects. Eur J
Clin Nutr 2007;61:11061113.
41 Todd AS, Macginley RJ, Schollum JB, Johnson RJ, Williams SM, Sutherland WH, et
al:Dietary salt loading impairs arterial vascular reactivity. Am J Clin Nutr 2010; 91:
557564.
42 Tholstrup T, Ehnholm C, Jauhiainen M, Petersen M, Hy CE, Lund P, et al: Effects of
medium-chain fatty acids and oleic acid on
blood lipids, lipoproteins, glucose, insulin,
and lipid transfer protein activities. Am J Clin
Nutr 2004;79:564569.

Ann Nutr Metab 2013;63:159167

DOI: 10.1159/000354868

167

Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.