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Research Article

The Effect of Weight Reduction Diet on C-Reactive Protein Level in Obese-Adult Subjects

Adel A. Al-Hamdan, Rabba H. Al-Huthail, Mohamed A. Alsaif, Abdulaziz M. Al-Othman, May N. Al-Muammer, Saada M. Al-Orf, Abdallah A. Saeed and Badreldin A. Mohamed
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To study the effect of weight-reduction diet (WRD) on serum high sensitivity C-reactive protein (hs-CRP) level in obese-adult subjects admitted to Riyadh Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia. Fifty three subjects with body mass index (BMI) ≥ 30 kg m-2 were included in the study. They were placed on energy-restricted diet for 12 weeks. Diet history and food-frequency questionnaire were filled before starting the WRD. Anthropometric measurements [weight, height, BMI and waist circumference (WC)] were taken and blood samples were collected to analyze hs-CRP, total cholesterol, triglyceride, high-density lipoprotein-cholesterol and low-density lipoprotein-cholesterol before and at the end of the WRD. There is a significant reduction in BMI and WC after applying the WRD program. In addition, hs-CRP level, triglyceride and total cholesterol were significantly reduced after applying the WRD. A significant positive correlation was noted between serum hs-CRP level and measures of adiposity, such as BMI and WC. hs-CRP level is influenced by WC and by BMI in obese-adult subjects and that the WRD decreases serum level of hs-CRP.

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  How to cite this article:

Adel A. Al-Hamdan, Rabba H. Al-Huthail, Mohamed A. Alsaif, Abdulaziz M. Al-Othman, May N. Al-Muammer, Saada M. Al-Orf, Abdallah A. Saeed and Badreldin A. Mohamed, 2009. The Effect of Weight Reduction Diet on C-Reactive Protein Level in Obese-Adult Subjects. Journal of Medical Sciences, 9: 17-23.

DOI: 10.3923/jms.2009.17.23



C-reactive protein (CRP) is an acute-phase protein that is elevated several hundred-folds in response to infection and is considered to be a good marker of inflammation (Baltz et al., 1982; Pepys, 1996; Ridker, 2003). CRP is one of the markers predicting future cardiovascular disease. Several studies have reported that the risk for cardiovascular disease was positively associated with CRP levels (Tracy et al., 1997a, b; Danesh et al., 1998; Koenig et al., 1999; Rohde et al., 1999; Ridker, 2000; Ridker et al., 2000a). Ridker et al. (2002) have found that CRP is a better marker than low density lipoprotein-cholesterol (LDL-C) in predicting future coronary events and those subjects with high CRP and low LDL-C were at higher coronary risk than those with high LDL-C but low CRP. CRP is also positively associated with an increased risk of myocardial infarction and stroke (Ridker et al., 1997; Fored and Giles, 2000; Mendall et al., 2000; Ridker et al., 2000b; Rost et al., 2001).

Obesity and accumulation of fat surrounding the abdominal visceral organs is associated with a variety of serious health conditions (Kissebah and Krakower, 1994). A disturbance in lipoprotein metabolism, which is a risk factor for atherosclerosis, has been reported in subjects with an excessive deposition of adipose tissue at the abdominal level (Kissebah et al., 1989; Després et al., 1990).

Proinflammatory cytokines, including interleukine-6 (IL-6), is expressed in human adipose tissues and then released into the circulation (Purohit et al., 1995; Mohamed-Ali et al., 1997; Fried et al., 1998). Adipose tissue is estimated to produce about 25% of systemic IL-6 in vivo (Mohamed-Ali et al., 1997). Adipose tissue-derived cytokines, particularly IL-6, is involved in the elevation of CRP in obesity (Bastard et al., 1999). The inflammatory properties of the proinflammatory cytokines, including the stimulation of acute-phase protein production in the liver, mild elevation of serum inflammatory cytokines and CRP may explain the increased cardio and cerebrovascular morbidity and mortality, particularly in morbidly obese patients (Flegal et al., 2002). The relationship between nutritional status and CRP level is ill defined. To the best of our knowledge no study has been conducted in KSA to assess the affect of dietary intervention on C-reactive protein level. Nationwide studies in the Kingdom of Saudi Arabia (KSA), reported an overall prevalence of 36.9% for overweight and 35.6% for obesity among adult Saudi males (Al-Nozha et al., 2004, 2005).

The main objective of the study is to examine the effect of weight-reduction diet (WRD) on high sensitivity CRP (hs-CRP) level in obese-adult subjects at Riyadh Armed Forces Hospital (RAFH), KSA.


Setting: The study was conducted at RAFH, Riyadh, KSA. RAFH provides medical services for the military personnel and their dependents in KSA.

Subjects: Fifty three obese adults (age 18-60) with a body mass index (BMI) ≥ 30 kg m-2 referred from primary health care clinics to the nutrition clinic who satisfied inclusion criteria were included in the study. The exclusion criteria were: the presence of diabetes mellitus, cardiovascular disease, hypertension, inflammatory and autoimmune diseases and the use of anti-inflammatory or lipid-lowering drugs.

The study was approved by the local ethics committee. All participants gave their informed consent, after a full explanation of the nature of the study and the data collected will be used only for the stated research objectives.

Data collection: Data collection was carried out over a period of 5 months (from the 8th of February 2005 to the 9th of July 2005). The subjects were instructed to follow a WRD for a period of 12 weeks and written material diet sheet was provided. As the study duration is limited, the total energy content of the WRD was restricted to 1200 kcal, in which macronutrients constitute [50% carbohydrate (40% complex carbohydrate), 20% protein (14% high biological value protein) and 30% fat (10% saturated, 13% unsaturated and 7% monounsaturated fat)] of total kcal. Subjects were asked to visit the nutrition clinic every 3 weeks for dietary counseling and weight check.

Before starting the WRD program, demographic data and diet history were obtained. In addition, dietary habits were evaluated and the quantity of carbohydrate, protein and fat eaten by obese subjects at baseline, before entering the diet program, was estimated using the semi quantitative food frequency questionnaire.

Anthropometric variables: Anthropometric measurements and blood samples were taken before and at the end of the diet program. For anthropometric measurements, weight, height, BMI and waist circumference (WC) were measured. Subjects were weighed to the nearest 0.1 kg without shoes, with body weight evenly distributed between both feet using an electronic scale. Height was measured by a portable stadiometer and to the nearest 0.1 cm. BMI was calculated by dividing the weight in kilograms by the square of the stature in meters (kg m-2). WC is used to assess abdominal fat distribution. WC was measured as the smallest dimension between the lower rib margin and the iliac crest and it was measured to the nearest 0.1 cm.

Sample collection and preparation: Venous blood samples obtained by venesection of the antecubital fossa vein with a 21 gauge venflon needle were taken from subjects after fasting for 9 h. The serum was separated and stored at -70 °C until analysis. Serum lipid concentrations [total cholesterol (TC), high density lipoprotein-cholesterol (HDL-C) and triglyceride (TAG)] were measured by enzymatic colorimetric methods using commercial reagent sets (Roche Diagnostics). LDL-C was calculated using the friedewald formula (Friedewald et al., 1972): LDL-C = TC-HDL-C-TAG/5. Serum hs-CRP was measured using a high-sensitivity monoclonal antibody to CRP coated on polyesterene beads (Siemens Health Care Diagnostics, Riyadh, KSA). Serum hs-CRP >3.00 mg L-1 was considered as a high risk value for cardiovascular disease (Pearson et al., 2003).

hs-CRP was measured instead of the traditional CRP method. Both CRP and hs-CRP measure the same molecule in the blood. The hs-CRP test measures very small amounts of CRP in the blood and is ordered most frequently for seemingly healthy people to assess their potential risk for heart problems. It measures CRP in the range from 0.5 to 10 mg L-1. The CRP test is ordered for patients at risk for infections or chronic inflammatory diseases and it measures CRP in the range from 10 to 1000 mg L-1 (Leduc et al., 1998; Rifai et al., 1999), thus, hs-CRP was measured instead of the traditional CRP method.

Statistical analysis: Data were expressed as mean (M) ± standard deviation (SD). In addition to the descriptive statistics, mean values at baseline and at the end of the diet program were compared using paired t-test. Correlation analysis were performed by calculating pearson correlation coefficient (r). A p-value of <0.05 was considered significant in all statistical tests. All statistical tests were computed using SPSS version 14 for Windows.


The data obtained for males, females and age were combined, since present results showed no gender difference in hs-CRP concentration (t-test; p = 0.334) and no age differences (ANOVA, p = 0.677). The general characteristics of the study sample are shown in Table 1. The majority of the subjects were females (81.1%), mostly married (67.9%) and about 74% of the subjects had educational level below the university level. Most subjects (81.2%) had monthly income of ≥ 3000 Saudi Riyal (1 US Dollar = 3.75 Saudi Riyal) and about 55% were unemployed. Using the semi-quantitative food frequency questionnaire, the results showed that the mean energy intake of the subjects, before entering the WRD program, was 3006 kcal day-1 and the percentage of energy intake from fat was high (Table 2).

Table 1: General characteristics of subjects

Table 2: Daily average energy intake and macronutrient intake of the subjects at base line
Total energy intake is presented as Mean ± SD. Energy intake from macronutrient is presented in percentage (%) of total energy intake

Table 3: Anthropometric measurements and serum hs-CRP level of the subjects before and after applying the diet program
BMI: Body mass index; WC: Waist circumference; hs-CRP: C-reactive protein

Table 3 shows the anthropometric measurements and serum hs-CRP level of the subjects before and after the diet program. There were significant reductions in BMI, WC and hs-CRP level after applying the diet program when compared to the baseline. Table 4 displays the classification of subjects according to their hs-CRP level, at baseline and post treatment. The result demonstrated that more than half of the subjects had a high level of hs-CRP at base line, before starting the diet program. The percentage was reduced to 49% after the diet program was implemented. Table 5 presents the lipid profile of the subjects before and after implementing the diet program. There was significant decrease in the serum TC and TG concentrations, after applying the program. A reduction in the serum LDL-C and HDL-C concentrations occurred, after applying the diet program, but it was not significant. The main meal for two thirds of the subjects (66%) was lunch and about half of the subjects skip breakfast. Nearly half of subjects consume whole fat dairy products and 43.4% of the subjects used to consume one snack daily (data not shown).

Table 4: Classification of subjects according to their C-reactive protein level before and after applying the diet program
hs-CRP: C-reactive protein R; CHD: Coronary heart disease

Table 5: Comparison between lipid profile of the subjects before and after applying the diet program
TC: Total cholesterol; LDL-C: Low density lipoprotein-cholesterol; HDL-C: High density lipoprotein-cholesterol; TG: Triglyceride

Table 6: Correlation between various parameters and hs-CRP before and after implementing the diet program
BMI: Body mass index; WC: Waist Circumference; hs-CRP: C-reactive protein; TC: Total cholesterol; LDL-C: Low density Lipoprotein-cholesterol; HDL-C: High density Lipoprotein-cholesterol; TG: Triglyceride; r: Correlation coefficient

Table 6 outlines the correlation between hs-CRP and different parameters before and after applying the diet program. A significant positive correlation was found between hs-CRP and BMI or WC, either before or after implementing the diet program.


Several prospective epidemiologic studies have demonstrated a positive association between CRP levels and the risks of future cardio-vascular disease (Liuzzo et al., 1994; Thompson et al., 1995; Kuller et al., 1996; Haverkate et al., 1997; Tracy et al., 1997a, b; Koenig et al., 1999; Ridker et al., 2002). It has been suggested that blood CRP levels reflect the amount and activity of pro-inflammatory cytokines. There was a significant reduction in IL-6, by following a low-calorie diet and a trend toward reduced hs-CRP was noted, but the reduction was not statistically significant, after weight loss in obese women (Bastard et al., 2000). The insignificant reduction in CRP levels, after weight loss, could be attributed to the short duration of the weight loss program (3 weeks) and smaller number of subjects (n = 14) enrolled in their study. In the present study, hs-CRP decreased significantly, after the WRD program was applied.

WC and waist-to-hip ratio are the two most commonly used anthropometric measurements for the prediction of visceral adipose tissue. WC correlates with visceral adipose tissue more than the waist-to-hip ratio index (Simone et al., 1996). Abnormal WC is associated with disturbances in lipoprotein-lipid profile and even at the same level of overweight, an individual with a greater amount of visceral fat is more likely to have many of the metabolic complications, including cardiovascular disease (Montague et al., 1997; Stevens, 1995; Conway et al., 1995; Larsson, 1988). In a population-based study of 186 healthy women aged 43 to 55 years, Hak et al. (1999) reported that CRP was strongly related to WC, even after adjustment for BMI. They suggested that abdominal fat deposition could be an important determinant of inflammatory metabolic state. A significant positive correlation was also noted between CRP levels and BMI (Mendall et al., 1997; Tracy et al., 1997a, b). Approximately 25% of circulating IL-6 is estimated to be released by human subcutaneous adipose tissue in vivo and IL-6 stimulates the production of CRP in the liver (Nesbitt et al., 2004; Al-Qahtani et al., 2005). This might explain the reduction in hs-CRP levels and the positive association that was found between hs-CRP level and BMI or WC, either before or after applying the diet program (Table 6).

Elevated CRP levels have been reported among subjects with high TG and low HDL-C (Mendall et al., 1996; Tracy et al., 1997a, b; Hak et al., 1999; Yudkin et al., 1999). The relationship between IL-6, CRP and lipid profile could explain the benefit of reducing weight and avoiding central obesity in reducing the risk of CHD. In the present study, hs-CRP level (Table 3), TC and TG (Table 5), were reduced after the WRD program was implemented, but no significant correlation was observed between hs-CRP and lipid profile (Table 6). Present finding is in agreement with Isabell et al. (2001) who found no significant correlation between plasma CRP levels and TC, TG, LDL-C, or HDL-C concentration in men aged 22 to 63 years.

To conclude, the results indicate that hs-CRP level is affected by BMI and WC in adults and that WRD decreases hs-CRP level in obese-adult subjects. Applying a WRD program to healthy-obese subjects may help in reducing the risk of CHD by reducing the amount of adipose tissues and thus, may down regulate CRP production. Pro-inflammatory cytokines were not measured in the present study, thus, direct assessment of these cytokines is needed in future relevant studies.


Thanks to Mr. Khalid Al Helal, head of the dietetic department at the RAFH, for his support in conducting the study. The authors are also grateful to Dr. Samia sobki and her laboratory team at RAFH for their valuable assistant in the laboratory.

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