"The Treatment of Obesity
in an Outpatient Dietetic Unit"

JAMA paper, 1963 Dec 21 ,
pages 77-80 ,
Vol. 186, No. 12
by Blondheim MD,
Kaufmann MD,
Poznanski MS
(Jerusalem, Israel)

research that was inspiration
for the Atkins' lowered-carbs
approach to weight loss
and better health

(2008 Jan blog post)

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This page that shows the text of a 1963 December
JAMA article that provided basis for the 'Atkins diet'

INTRODUCTION :

Many critics of Dr. Atkins and his lowered-carbs diet seem to think he pulled his diet out of thin air.

The critics seem to lack the will to look up the texts that he credits with leading to his diet proposals.

    Ironically, many of his strongest critics are doctors in the AMA, American Medical Association --- and Atkins got his inspiration from papers published in the JAMA, Journal of the American Medical Association.

    Further irony:
    Those papers were written by doctors of the AMA --- and were reviewed and accepted for publication by doctors in the AMA.

The 'Atkins diet' (actually, a lifetime-way-of-eating methodology) was not invented by him.

Atkins was actually trying to popularize medical study results that he had read about in medical journal articles published back in the early 1960's --- for the benefit of his patients, for the citizens of this country, and for the citizens of the world.

In other words, he was trying to communicate important health information that was "locked away" in stuffy old medical journals, in and among pages of mind-numbing verbiage.

To quote Atkins in his book "Atkins for Life", 2003, page xii:

    "The first published documentation [link to a PDF file] of the success of a controlled carbohydrate dietary regimen appeared in the 1800s, but we needn't go back that far.

    It was after reading a scientific study on the effectiveness of several low carbohydrate weight-loss programs in the October 1963 issue of the Journal of the American Medical Association [JAMA] that I decided to put a similar approach into practice.

    We now have, on our web site www.atkinscenter.com, summaries of close to four hundred [ 400 ! ] scientific studies that support the principles upon which the controlled carbohydrate nutritional approach is based."

And in the back of the book "The Atkins Essentials" (2004) that was published after Atkins' death, there is a bibliography of 15 peer-reviewed studies, published in 2001 to 2003, that specifically focused on the outcomes that result from the "Atkins Nutritional Approach".

Many of these recent studies come from respected researchers at institutions such as Harvard and Stanford --- again, members of the AMA. I find it amazing that people (many of them doctors and dieticians) who debunk lowered-carbs diets can simply ignore these studies, or pass them ALL off as invalid.

Hopefully, these more recent studies were done with even more rigor than the study documented on this page.

    I would have liked to see the weight-loss results of this study presented as %-of-body-weight as well as in pounds and kilograms --- to accomodate the different sizes of the 62 men and women in the study.

    Because these were obese patients, the women probably weighed much more than 150 lbs and the men probably weighed much more than 200 lbs. Hence the goal of a 20 pound loss in any of them, no matter their height or their recommended weight, was apparently considered appropriate, in the limited time-frame of the study.

In spite of the way the weight loss was presented, I think that you will see below that there is good reason to try to maintain a "lowered-carbs" diet, like the one reported here (35-35-30, protein-fat-carbs) --- based heavily on vegetables and some fruit, as well as protein sources --- soy protein, for vegetarians.

    The typical ratios recommended in "low-fat" diets is 35-20-45 protein-fat-carbs, or thereabout.

    Note the high proportion of carbs, substituting for fats. This study suggests that such an increase in starchy carbs is NOT a good idea.

Simplification of the Atkins Diet :

If you don't like to try to keep track of the ratio of protein-to-fat-to-carbs that you are eating (I sure don't) --- and if you don't like to count calories and grams (I sure don't), as a simpler alternative, then just try the 'No Flour, No Sugar Diet' proposed by Dr. Gott M.D. in a book by that name.

Dr. Gott realizes that it is just too much to expect that people can and will do food-components data-gathering and calculations --- especially on a day-to-day basis.

    By the way, Dr. Gott, I would guess, is a member of the AMA --- unless he has been driven out by anti-lowcarb-diet doctors high up in the AMA hierarchy.

    Dr. Gott's "lowered-carbs"-views, and, especially, the publishing of those views for the world to see, must have made him the target of powerful 'sugar-and-starch carbohydrate interests'.

    I have to wonder what is driving those anti-lowcarb-diet AMA doctors to 'bad mouth' Atkins so vehemently. Monetary ties to soft-drink-AND-candy-AND-processed-foods-AND-drug-AND-insulin industries ???

Medical reports that inspired the 'Atkins diet' :

The "scientific study" link above takes you to a web page at this site that gives you the majority of the text of the Oct 1963 report that Atkins refers to --- i.e. the study that led to his many years spent in formulating and fine-tuning and promoting a lowered-carbs way of eating, to help many of his patients --- and ultimately anyone who was in need of help and who would listen.

I could no longer find the Oct 1963 article on-line on the internet.

Even the JAMA web site does not have journal articles on-line that the JAMA published before the mid-1960's.

So I found the article in a university medical school library --- and I have devoted some hours to keying in the major part of the text, so that the article is preserved on-line.

In finding that Oct 1963 JAMA article, I ran across a Dec 1963 JAMA article that Atkins probably saw --- the text of which appears on this page.

    NOTE:
    I have added bold font to some statements of the report that seemed especially important to me, based on my experiences. And I have inserted some notes. Those notes are enclosed in square brackets. To aid in readability, I have broken some large paragraphs into smaller paragraphs of one or two sentences.

The Dec 1963 article takes a more "clinical-data-only" approach, than the "biochemistry-oriented" Oct 1963 article, in pointing out the benefits of a lowered-carbs diet.

The results come from a "dietetic outpatient clinic" --- and the paper says in the introductory summary, that patients "came to eat a low-carbohydrate, high-protein diet". That probably caught Atkins' eye --- along with the term "obesity" in the title.

Since that article probably erased any doubts that Atkins may have had about the likelihood of success in trying a lowered-carbs way of eating, I have keyed in a majority of the text of that Dec 1963 article ... below.

Read the Oct and Dec 1963 texts yourself.

See if you would have come to the same course of action that Atkins pursued, if you had a medical practice like he had.

The Treatment of Obesity
in an Outpatient Dietetic Unit

Solomon H. Blonheim MD,
Nathan Kaufmann MD,
and Rachel Poznanski MS
Jerusalem, Israel

JAMA Vol. 186, No. 12,
pages 77-80,
1963 Dec 21

From the Dietetic Unit of the Hadassah-University Hospital,
the Hebrew University-Hadassah Medical School, and
the Israel Government College of Nutrition

    Summary:
    Obese patients were treated in an outpatient dietetic unit to which they came to eat a low-carbohydrate, high-protein diet totaling 1,000 calories. Close physician-patient and dietician-patient relationships built up in this setting, which included a strong element of group therapy, provided essential emotional support. The results were encouraging: 73% of the first 62 patients lost 20 lb (9.1 kg) or more.

The results of the treatment of obesity have been almost uniformly unsatisfactory [1].

When patients are treated in an outpatient clinic, many fail to lose any weight and most lose only minor amounts.

Patients treated with a conservative low-calorie diet in the hospital usually start to lose weight satisfactorily.

However, since they rarely remain for more than a few weeks and seldom continue to lose weight on returning to their usual living conditions, total weight loss is far from adequate.

The place of the radical total or near-total 7- to 14-day fast started in the hospital [2][3] has yet to be evaluated as to both its merits, dangers, and other disadvantages.

We have evolved a system of treatment that is in effect a compromise that combines the best features of the hospital and outpatient treatment of obesity.

Although our diet is more generous both quantitatively and qualitatively than that of the reported series with the best results [4], we have had an even greater proportion of patients with satisfactory weight losses.


Methods :

Our outpatient dietetic unit includes an examining room, a dining room, and a kitchen separate from the usual hospital facilities.

The patients come three times a day to the hsopital to eat and are given a small snack to take home to eat before bedtime.

Up to 15 patients at a time undergo the four-week diet course in the unit and then continue the diet at home, returning for weekly to monthly checkups.

Occasionally patients continue to eat in the unit for six to eight weeks until they feel that they can face the prospect of continuing on their own.

Those who do not continue to lose weight satisfactorily at home may return to the unit for another week or fortnight to readapt to the diet.

The standard diet offered is low in carbohydrate and high in protein.

It consists of 1,000 calories of which at least 35% are derived from protein, about 35% from fat, and about 30% from carbohydrate.

    [Note the 35-35-30 protein-fat-carbs ratio!

    Note that fat is NOT eliminated, and note that the 30% carbs is much lower than the 45% that is typical of low-fat diets, but still far from 0%.

    In other words, it is a balanced diet of protein-fat-carbs.]

Protein is supplied as lean meat, fish, cottage cheese, egg, soya flour, and skim milk yoghurt.

Eggplant, vegetable-marrow, cabbage, lettuce, and tomato are the main vegetables served.

At least two portions of fruit are provided a day, but only one slice of bread.

Occasionally, the diet is reduced to 800 calories or increased to 1,200 in special instances.

Vegetarians are also accommodated, with much of their protein coming from soya flour.

The minimum daily vitamin requirements are met by the diet so that the patient can lose weight on diet alone, without supplementary pills or medication.

Only when salt and water retention becomes more than a transient problem are diuretics employed; occasionally a mild tranquilizer is prescribed.

No anorexigenic agents are used, nor are thyroid preparations, except in the case of marked hypothyroidism.

If constipation becomes a problem, detergent and medicated suppository preparations are advised.

During the four weeks the patient eats in the unit (exclusive of Friday evening and Saturday) he is seen at least two to three times a week by the physician.

The need for support and encouragement during the stress of reducing is fully recognized and a large measure of informal nondirected psychotherapy is extended when needed, during which psychological and especially psychiatric terms are strictly avoided.

Spontaneous catharsis is often resorted to by the patient, but in the rare instances when there appears to be a need for more reassurance and general advice, the patient is referred to a psychiatrist.

A warm doctor-patient relationship usually develops, but some patients make closer contact with the senior dietician, whom they see twice daily.

The 62 patients included in this report (21 men, 41 women). ranged in age from 14 to 68 years.

A full history was taken on each patient and a complete physical examination performed before start of treatment.

The most frequent medical problems in addition to obesity per se were hypertension, osteoarthritis of the knees, chronic phlebitis [inflammation of veins] of the legs, and sterility.

The economic and social backgrounds of the patients were most varied.

Some were in the lower economic strata and were referred by the workers' sick fund, while others paid full private rates.

The sociological range extended from a 13-year-old daughter of a widowed laundress to a cabinet minister.


Results :

Of the 62 patients who began the course of treatment in the unit ten weeks or more before preparation of this preliminary report, 16% lost 40 lb (18.2 kg) or more, and 57% lost between 20 and 39 lb (9.1 - 17.8 kg).

Sixty-eight per cent of the women and 81% of the men lost 20 lb or more.

Of the 45 patients who lost 20 lb or more, 21 ate in the unit for longer than four weeks at the start of the treatment, while five of these latter and four other patients returned for one or more courses of one to three weeks in the unit.

Of the 62 patients who started the four-week course, only three did not complete it.

In two cases, illness prevented completion.

Of the 17 patients who lost less than 20 lb and are considered treatment failures, nine appear to have given up the attempt to achieve a satisfactory weight loss.


Comment   [summary]

The voluminous literature documenting the unsatisfactory results in the treatment of obesity was comprehensively reviewed by Feinstein [5].

The great majority of reports are deficient because they do not classify patients by the amount of weight each lost, or do not give the total number of patients who started treatment ("not totally reported").

In Feinstein's tabulations, there are only 12 outpatient series of more than 30 cases each without these deficiencies.

(Beck and Hubbard's series is listed by Feinstein, although not totally reported.)

To these we have added six other series.

The best results obtained so far in the treatment of outpatients have been those of Feinstein et al [4], who started 57 patients in their outpatient obesity research clinic on a 900-calorie, low-protein, liquid-formula diet.

Of these patients, 56% lost 20 lb or more, a convenient comparative index of success often used in the literature.

Feinstein [5] also collected five series of patients treated at a "nutritional table", similar to ours.

However, these series are too small for reliable comparison, the largest including only 12 patients.

Furthermore, the patients were mostly young volunteers in a college setting and are not comparable with the usual clinic or private patient population.

If the three separately reported college series of Young and her respective co-workers are cumulated, they total 24 patients, 54% of whom lost 20 lb or more. [6][7][8]

Other hospital dietetic units similar to ours do not appear to have reported their results.


The results of our series of mixed clinic and private patients, with 73% losing 20 lb or more, are more than twice as good as most series, half again as good as the best solid food series [9], and a third better than the best liquid-formula series [4].

In terms of abject failures who lost less than 10 lb, our rate of 6% is less than a half that of the best series in this respect [9], while in terms of the most successful patients who lost 40 lb or more, our 16% rate is better than any except that of the best liquid-formula series [4].

Moreover, since many of our patients are still losing weight, our rate for this category is potentially even higher.

We attribute the encouraging results of our system to its workable compromise between the inpatient and the outpatient treatment of the obese patient, combining to a large extent the best features of both.

Patients who are not really sincere in their professed desire to start and maintain a dieting program do not present themselves for treatment at the unit, as they do so often at the outpatient clinic.

On the other hand, those patients who are willing to submit themselves to the discipline of the unit and make the necessary investment of time and effort required, almost never "cheat" to an extent that interferes with satisfactory weight loss.

In only two of our 17 treatment failures was "cheating" while eating in the unit the cause of failure.

As have others [10], we found the daily official weighing-in a most potent means of impersonal discipline preventing the patient from falling into the "feast today, fast tomorrow" fallacy.

Another marked advantage of the unit is the effective re-education of dietary habits, such as eating a relatively full breakfast to forestall the pangs of hunger that lead to increased caloric intake.

Since the diet consists of solid food and not of a liquid formula, the patient is better prepared, after satisfactory weight loss, to follow a normal diet rather than return to his former diet on which he became obese [11].

The emotional support provided by physician and dietician is almost equal in intensity to that provided in the hospital.

In addition, the factor of group therapy at the diet table is most helpful.

It [the group] provides suggestions for solving common problems, encouragement for those just starting the diet, an element of competition for those in later phases of treatment, and sympathetic support for all during periods of unusual stress, physical or mental.

Group therapy as such has been found helpful by others in the treatment of obesity [12][13].

Our unit is well located in an annex of the hospital situated between a main business district and a residential area.

However, hospitals in larger cities may also find outpatient dietetic units convenient for large sections of the obese population.

Units in hospitals in predominantly business or industrial distrincts can serve those working near them, while tose in predominantly residential districts can serve housewives and adolescent school children.

So far, only three of our 45 patients who lost 20 lb or more have regained more than 30% of the weight they lost.

However, since most of our patients have been followed for less than a year, it is much too early to hazard an opinion as to whether our system will give better long-term results as well.

Balfour 9, Jerusalem, Israel (Dr. Blondheim)

Mrs. Esther Franckenberg is the senior dietician of the unit.

This study was supported by a fund established in memory of Julius Brodie, Harris N. Brodie, and Anna Leah Brodie.

Soya flour was supplied by the Soybean Council of America Inc., Israel office.


References

1. Stunkard, A., and McLaren-Hume, M.:
Results of Treatment for Obesity,
Arch. Intern. Med. (Chicago) 103:79-85, 1959.

2. Bloom, W.L.:
Fasting as Introduction to Treatment of Obesity,
Metabolism 8:214-220, 1959.

3. Duncan, G.G., et al:
Correction and Control of Intractable Obesity,
JAMA 181:309-312, 1962.

4. Feinstein, R., Dole, V.P., and Schwartz, I.L.:
Use of Formula Diet for Weight Reduction of Obese Outpatients,
Ann. Intern. Med. 48:330-343, 1958.

5. Feinstein, A.R.:
Treatment of Obesity: Analysis of Methods, Results, and Factors which Influence Success,
J. Chronic Dis. 11:349-393, 1960.

6. Young, C.M.:
Weight Reduction Using Moderate-Fat Diet: Clinical Responses and Energy Metabolism,
J. Amer. Diet Ass. 28:410-416, 1952.

7. Young, C.M., Ringler, I., and Greer, B.J.:
Reducing and Post-reducing Maintenance on Moderate-Fat Diet: Metabolic Studies,
J. Amer. Diet Ass. 29:890-896, 1953.

8. Young, C.M., et al:
Weight Reduction in Obese Young Men: Metabolic Studies,
J. Nutr. 61:437-456, 1957.

9. Halpern, S.L.:
Effective Weight Reduction, New York
J. Med. 61:4205-4212, 1961.

10. Crane, S.:
Action of Chorionic Gonadotropin in Obese,
Lancet 1:1283, 1961.

11. Formula Diets and Weight Control,
report of the Council on Foods and Nutrition,
JAMA 176:439, 1961.

12. Harvey, H.I., and Simmons, W.D.:
Weight Reduction: Study of Group Method: Report of Progress,
Amer. J. Med. Sci. 227:521-525, 1954.

13. Munves, E.D.:
Dietetic Interview or Group Discusion - Decision in Reducing?
J. Amer. Diet Ass. 29:1197-1203, 1953.

14. Evans, F.A.:
Treatment of Obesity with Low Caloric Diets,
JAMA 97:1063-1068, 1931.

15. Roberts, H.J.:
Long-Term Weight Reduction in Cardiovascular Disease: Experiences with Hypocaloric Food Mixture (Metrecal),
J. Amer. Geriat. Soc. 10:308-347 (April) 1962.

16. Fineberg, S.K.:
Obesity-Diabetic Clinic,
JAMA 181:862-865 (Sept 9) 1962.

17. Hendon, J.R., and Arback, S.:
Use of Diethylpropion in Obese Diabetic Patients,
Metabolism 11:327-341 (March) 1962.

18. Berkowitz, D., and Beck, N.:
Long-Term Management of Obesity in Union Health Center: Analysis of Successes and Failures,
JAMA 172:1381-1383, 1960.

19. Musgrave, P.W.:
Rapid Weight Reduction for Aircrews,
Aerospace Med. 33:1332-1343 (Nov) 1962.

[ Introduction to the table : ]

"Only series of more than 30 cases which include results of all patients starting diet are listed.

Table is based on Feinstein [9], except for the six series with reference numbers.

Musgrave [19] has reported extraordinarily good results with male Air Force personnel under military discipline.

For these men, the potential loss of flying pay constituted a very strong motivational factor."

    [Note:
    There is probably something to be learned here. Employers, insurance companies, and governments could benefit by providing motivational factors to encourage employees/the-insured/citizens to maintain a health-potentiating weight. We see nowadays, 2007-plus, a few news stories along these lines. May there be more.]

    [NOTE:
    The last column is the sum of the previous two columns.]

Weight Loss, % of patients
Series, Year Environment, Technique Calories No. of
patients
Less than
10 lb (4.5 kg)
10-19 lb
(4.5 - 8.6 kg)
20-39 lb
(9.1 - 17.8 kg)
40 lb (18.2 kg)
or more
20 lb (9.1 kg)
or more
Munves, 1953 Individual interviews
or group discussion
1,200-1,800 48 71 21 8 0 8
Joliffe, 1951 Nutrition clinic; citrus juice as anorexigenic 1,000-1,400 73 53 36 11 0 11
Stunkard, 1959 Nutrition clinic 800-1,500 100 ... ... 11 1 12
Evans, 1931 [14] Private office; occasional use of thyroid 600 130 59 19 17 5 22
Bauman, 1928 Obesity clinic 1,200 183 50 27 ... ... 23

Weight Loss, % of patients
Series, Year Environment, Technique Calories No. of
patients
Less than
10 lb (4.5 kg)
10-19 lb
(4.5 - 8.6 kg)
20-39 lb
(9.1 - 17.8 kg)
40 lb (18.2 kg)
or more
20 lb (9.1 kg)
or more
Harvey, 1954 Group psychotherapy project 1,000 290 47 30 ... ... 23
Roberts, 1962 [15] Private office (cardiacs); started on liquid formula, continued on solid diet 900-1,000 78 27 48 ... ... 25
Fellows, 1931 Employees clinic self-selected 294 47 27 21 5 26
Gray, 1939 Nutrition clinic 900 314 52 20 21 7 28
Young, 1955 Experimental nutrition clinic Various diets 156 ... ... 25 3 28
Hawirko, 1946 Private office; routine amphetamine 1,100 162 55 17 23 5 28
Osserman, 1951 Metabolism clinic (diabetics); routine amphetamine 1,000 55 35 36 27 2 29
Barnes, 1958 Weight reduction clinic; routine methamphetamine HCl + phenobarbital (ambar) (anorexigenic) 800-1,100 50 ... ... 26 8 34
Fineberg, 1962 [16] Obesity-diabetes clinic; routine phenmetrazine HCl 1,000 43(?) ... ... 42 0 42
Hendon, 1962 [17] Endocrine clinic; routine diethylpropion HCl ? 40 38 20 37 5 42

Weight Loss, % of patients
Series, Year Environment, Technique Calories No. of
patients
Less than
10 lb (4.5 kg)
10-19 lb
(4.5 - 8.6 kg)
20-39 lb
(9.1 - 17.8 kg)
40 lb (18.2 kg)
or more
20 lb (9.1 kg)
or more
Berkowitz, 1960 [18] Union health officer; routine amphetamine ? 100 22 17 35 7 42
Halpern, 1961 [9] Private office (?); amphetamine or vitamin-mineral candy for most patients up to 1,200 80 14 39 46 1 47
Feinstein, 1958 Obesity research clinic; low-protein liquid formula 900 57 [a] 23 21 30 26 56
Blondheim et al, 1963
(this paper)
Outpatient dietetic unit; no anorexigenic agent, occasional use of tranquilizers 1,000
[+/- 200]
61 6 21 57 16 73
Series, Year Environment, Technique Calories No. of
patients
Less than
10 lb (4.5 kg)
10-19 lb
(4.5 - 8.6 kg)
20-39 lb
(9.1 - 17.8 kg)
40 lb (18.2 kg)
or more
20 lb (9.1 kg)
or more

[a] Only patients starting treatment in clinic included. [Feinstein, 1958]

FOR MORE INFO :

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Bottom of this page of text from the
JAMA paper, 1963 Dec, titled
"The Treatment of Obesity in an Outpatient Dietetic Unit"
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A JAMA 1963 October paper and this paper were motivators of Dr. Robert Atkins, leading him to fine-tune and promote a lowered-carbs diet.

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This blog content was posted 2008 Jan 29.

Page was changed 2009 Aug 23.
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Page was changed 2013 Apr 28.
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