The S.D.M.

Dietary Protocol
research and development studio
S.D.M. s.r.l.
Societ Dietetica Medica
Via dellArtigianato 45
12038 SAVIGLIANO (CN)
Tel. +39 0172 64 80 00
Fax +39 0172 64 88 70
info@menopeso.it
www.dietasdm.it

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Printed in Italy - S.D.M. 2016
 Preface

S
ince 1995/1997 S.D.M., the Societ-Dietetica-Medica (Medical
Dietary Society), has offered effective, easy-to-manage instruments
for the treatment of excess body weight and, consequently, of
weight-related pathologies. The S.D.M. protocol was developed in
collaboration with Professor Marineau, a student of Professor Blackburn,
creator of the first Protein Diet protocol.

The S.D.M. protocol is strictly medicalized and enables the expert

nutritionist to achieve excellent results in reduced timespans.

S.D.M. gives paramount importance to the quality of its products and

uses the latest technology to ensure foods with high nutritional value,
in compliance with European H.A.C.C.P and ISO 9001 standards. The raw
materials used come entirely from European sources, in conformity with
EU legislation.

Uniquely in Italy, S.D.M. aims not only to support the nutrition expert
in prescribing and managing the dietary therapy, but also to accompany
its customers during their weight-lossprocess.

S.D.M. srl
Societ Dietetica Medica

3
 Index
Preface 3

Brief history 5

The method 6

Molecular mechanisms 6
Who the S.D.M. protocolis for 9
Who should NOT use the S.D.M. protocol 9
Advantages of the S.D.M. protocol 10
For the nutrition expert
For the patient
Possible mild side effects of the S.D.M. protocol 11

Macro- and micro-nutrientsin the S.D.M.diet 12

Carbohydrates 12
Proteins 12
Lipids 13
UNICOMPLEX 13
Fluid intake 13

Management of the patient 14

First appointment 14
Subsequent appointments 14

The S.D.M.dietary therapy 15

Attack phase 15
The classic diet 15
Example day 16
The mitigated diet 17
Example day 18

Transition 19
Introduction
The metabolic response of the body to calorie restriction in VLCKD and the
need for gradual increase in calorie intake 19
The four steps of the transition 22
Transition 1stStep 22
Transition 2ndStep 23
Transition 3rdStep 23
Transition 4th Step 23
Transition phase following a weight-losing diet with 3 meals 24
Transition phase following a weight-losing diet with 4 meals 25
Transition phase following a weight-losing diet with 5 meals 26
Transition phase following a weight-losing diet with 6-7 meals 27

Maintenance 29

Conclusions 30

References 31
4
 Brief history

I
n 1971, after extensive studies, Professor Blackburn, a professor at
Harvard University, outlined the principles of the Protein Diet, which
he defined as Protein Sparing Modified Fasting (Lidner and Blackburn
1976).

Later, in 1975, Professor Marineau, his student, defined the protocol

as Jeuneproteine (protein fasting) for a clearer distinction between
Blackburns method and the high-protein Atkins-type diets (Marineau
2004).

In the following years, the protocol method (which is best defined

as a Very Low Calorie Ketogenic Diet, VLCKD) spread rapidly and
internationally among nutrition specialists: millions of patients have
been treated successfully.

In 1993 the Ministry of Health of the United States, through a task

force, validated the VLCKD protocol (JAMA 1993). In the same period
S.D.M., in close collaboration with Professor Marineau, developed the
method on which the current protocol is based.
In 2003, the Finnish Ministry suggesteda VLCKD as first-line therapy for
the treatment of obesity associated with risk factors (type 2 diabetes
mellitus, insulin resistance, dyslipidaemia, hypertension).

In 2014 the Italian Association of Dietetics and Clinical Nutrition (ADI)

suggested the ketogenic diet as a validated clinical therapy for the
treatment of obesity and its complications (Pezzana, Amerio et al.
2014).

5
 THE METHOD

The method

T
he S.D.M. protocolconsists of a normo-protein Very Low Ketogenic Diet (VLCKD < 800 calories)with a low
carbohydrate content (about 50-70g of carbohydrates per day).

The protocol has three phases:

I Attack phase: ketogenic metabolism is triggered by the reduced carbohydrate intake. As an accessory phe-
nomenon to lipolysis and the catabolism of the fat reserves of adipose tissue, there is a physiological production
of ketone bodies (aceto-acetate, -hydroxybutyrate, acetone), which are a water-soluble share of energy, readily
available to many of the tissues of the body (brain, heart and muscle). Continuedketogenesis, besidesproviding an
adequate energy supply, is important to ensure the absence of hunger and the feeling of wellbeing throughout
the period of weight-loss.

II Transition phase: gradual reintroduction of traditional foods. In this phase the patient is re-educated to a
healthy and correct lifestyle, in order to optimise and stabilise the results obtained in the attack phase.

III Mediterranean diet: the patient has achieved the overall targets agreed with the nutrition expert and starts
correct long-term nutritional behaviour following the RDAs (Recommended Daily Allowances of nutrients and
energy).

S.D.M. offers specific products for the first and second phases. Transition phase products can also be used in the maintenance
of the dietary equilibrium.
The S.D.M. method provides patient with an amount of high biological value proteins that is calculated on the estimated
ideal weight (from 1 to 1.4 g (max.) of protein/kg ideal body weight/day). The S.D.M. method is therefore safe and suitable
for a broad spectrum of patients, even complex ones, unlike the high-protein diets (EFSA Panel on Dietetic Products Nutrition
and Allergies 2015).

Molecular mechanisms

T
he S.D.M. dietary protocol has a reduced carbohydrate content, which lowers the levels of insulin in the blood
and reduces this hormones antilipolytic activity, in favour of an increase in glucagon levels. These effects result
in an increase in the catabolism of triglyceride reserves mobilised from white adipose tissue,which are hydrolysed by
lipoprotein-lipase and thereby converted into free fatty acids and glycerol (Nelson andCox2014). (Figure 1)

The fatty acids and glycerol are used only in part as an energy substrate: in detail, skeletal muscles use 40% of the free fatty
acids, while hepatocytes transform 10% of the mobilised glycerol into glucose (Alberts, Johnson et al., 2002 ). (Figure 1)
The rest of the glycerol and fatty acids is metabolised in the liver in the processes of gluconeogenesis and ketogenesis,
respectively. Gluconeogenesis represents the metabolic pathway for synthesising glucose from non-carbohydrate sub-
strates and is triggered rapidly in the absence of glucose, through the effect of glucagon. Ketogenesis is the reversible pro-
cess of condensation of acetyl-CoA molecules through which ketone bodies (acetone, acetoacetate and -hydroxy-bu-
tyrate) are synthesised and requires at least 24-48 hours to be activated (Nelson and Cox 2014). (Figure 2)

In the lack of glucose, ketone bodies are readily used as a source of energy by skeletal muscles, the central nervous
system and cardiac tissue. In these tissues, ketone bodies are oxidized to acetyl-CoA, the metabolic substrate of the
Krebs cycle. At the same time, the nutritional characteristics of the S.D.M. products (proteins of high biological value

6
 THE METHOD

and limited carbohydrate content), ensure the stability of blood glucose, through the mechanism of hepatic and renal
gluconeogenesis (Nelson andCox2014). (Figure 1)

The latter phenomenon promotes a basal secretion of insulin which helps to keep the blood ketone levels stable: in fact,
a feedback mechanism between the levels of ketone bodies and the release of insulin is triggered. In this regard, insulin
plays a modulatory role on ketogenesis itself, making it impossible for pathological keto-acidosis, typical of type I or
insulin-dependent diabetes mellitus, to become established (Alberts, Johnson et al. 2002, Nelson and Cox 2014).

During the S.D.M. diet, the main source of energy comes from the catabolism of the lipidstores, thus causing an
efficient, rapid and steady weight loss at the expense of fat mass. In parallel, the lean body mass is preserved, thanks to
the contribution of normoprotein S.D.M. foods, thus improving the patients body composition.
In summary, the S.D.M. protocol, managed by a nutrition expert, is safe and effective for a wide range of patients,
including complex individuals.

Protein supply
Restricted supply of
Lactate carbohydrates
Gluconeogenesis
Aminoacids

Glucose
Ketone
bodies Other organs

Fatty acids Energy

Urea substrates
Glycerol

Triglycerides Urine

Figura 1. Thanks to the restricted intake of carbohydrates, the SDM diet lowers the levels of insulin in the blood and reduces the activity of this hormone,
promoting lipolysis and consequent ketogenesis, thereby providing the energy required to the central nervous system (ketones readily cross the blood-
brain barrier) and other tissues. The contribution of pre-assimilable protein supplements, of high biological value, effectively protects muscle mass.

7
 THE METHOD

Gluconeogenesis Glycolysis

Glucose Glucose

Glucose-6-phosphate Lipolysis

Phosphoenolpyruvate Pyruvate Hydrolysis of fatty acids

Ketone bodies

Acetyl CoA Acetoacetate Hydroxybutyrate

Oxalacetate Citrate
Acetate
TCA cycle
Malonate alpha-Ketoglutarate

CO2
Fumarate Succinate

Figura 2. Metabolic pathways activated in liver cells as a result of low blood glucose levels: gluconeogenesis,which produces glucose molecules, and
ketogenesis, which produces ketone bodies. The same pathways are used in the opposite direction in, respectively, gluco-dependent cells (adrenal cells
and red blood cells) and skeletal muscle and the central nervous system as a source of metabolic energy.

8
 THE METHOD

Who the S.D.M. protocol is for

Obese (BMI greater than 30) and overweight (BMI greater than 25) subjects (Lidner and Blackburn 1976, Sukkar,
Signori et al. 2013, Castaldo, Palmieri et al. 2015, Obesity August 25, 1993).

Overweight individuals with comorbid conditions(type II diabetes mellitus, dyslipidaemia, metabolic syndrome,
nocturnal apnoea syndrome, asthma) (Mobbs, Mastaitis et al. 2013, Paoli, Rubini et al. 2013, Feinman, Pogozelski et
al. 2015).

Pre-bariatric or obese patients, candidates for other types of surgery, to reduce the surgical/anaesthesiological
risk (Lidner and Blackburn 1976, Paoli, Rubini et al. 2013, Sukkar, Signori et al. 2013, Vesely and DeMattia 2014,
Castaldo, Palmieri et al. 2015).

Women who remain obese or overweight at the end of pregnancy and breastfeeding (Sumithran, Prendergast et
al. 2013).

Women in menopause (Sumithran, Prendergast et al. 2013).

Males and females with obesity-related Infertility and polycystic ovary syndrome (Mavropoulos, Yancy et al. 2005,
Kulak andPolotsky 2013).

Obese and over weight patients with migraine (Maggioni, Margoni et al. 2011, Di Lorenzo, Coppola et al. 2015).

Aesthetic reasons, localised adiposity.

Who should NOTuse the S.D.M. protocol

Subjects with type I, insulin-dependent diabetesmellitus.

Patients with severe liver failure (active chronic hepatitis, cirrhosis of the liver)

Patients with renal failure (serum creatinine greater than 1.5 mg/dl or GFR <60 ml/min).

Patients with serious cardiac disorders: heart failure, atrioventricular block, arrhythmias.

Patients who have had a myocardial infarction or stroke in the 3 months prior to beginning the dietary treatment.

Subjects with severe psychiatric disorders (especially eating behaviour disorders).

Individuals under treatment with non-potassium-sparing diuretics who have unbalanced hypokalaemia.

Subjects on chronic, systemic therapy with corticosteroids.

Pregnant and breastfeeding women (Sussman, Ellegood et al. 2013)

Children and adolescents during the growth phase.

(Mobbs, Mastaitis et al. 2013, Paoli, Rubini et al. 2013, Sussman, Ellegood et al. 2013, Armeno, Caraballo et al. 2014,
Castaldo, Palmieri et al. 2015, Paoli, Bianco et al. 2015, Paoli, Bosco et al. 2015).
9
 THE METHOD

Advantages of the S.D.M. protocol

For the nutrition expert:

Medicalised protocol.

Control of patient compliance with the dietary therapy (keturtest).

Simplicity of prescription.

Support from the company.

For the patient:

Lack of hunger and sensation of well-being (Gibson, Seimon et al. 2015).

Rapid weight loss.

Lean body mass preserved (Pezzana, Amerio et al. 2014, EFSA Panel on Dietetic Products Nutrition andAllergies2015).

Durable results.

Dietary re-education (Paoli, Rubini et al. 2013).

Harmonious weight loss and respect of skin elasticity.

Possible mild side effects of the S.D.M. protocol

Headache: analgesics.

Halitosis: S.D.M. mints q10.

Irregular bowel habit (constipation or diarrhoea): S.D.M. Fibromanna.

Transient alterations of the menstrual cycle.

Postural hypotension, dizziness, nausea,tachycardia: adapt supplementation of salts, S.D.M. UNICOMPLEX.

Muscle weakness: adapt supplementation of salts, S.D.M. UNICOMPLEX.

10
 THE METHOD

SYMPTOM DIAGNOSIS CAUSES TREATMENT

Using theKeturtest, check

Persistent hunger Intentional or unintentional Careful dietary and medication
for the presence of ketone bodies
Fatigue consumption of sugars history
in the urine

Competition of ketone bodies

Headache during the first Possible prescription
Interview and glucose in the central
2-3 days of analgesics
nervous system

Dizziness
Postural hypotension Interview Hyponatraemia Increase intake of fluids
Nausea Clinical examination causinghypovolaemia and sodium
Tachycardia

Check that S.D.M. UNICOMPLEX

Muscle weakness
Interview is being taken correctly and, if
Lumbago Hypokalaemia
Clinical examination necessary, increase the intake
Cramps
of potassium

Elimination of ketone bodies via

Halitosis Interview S.D.M. mints q10
the lungs

Increase fluid intake

Constipation Interview Change of diet Evaluate intake of oil and S.D.M.
Fibromanna

Fibre intake
Anti-diarrheal agent
Change of diet
Diarrhoea Interview Evaluate hydration and temporary
Decreased intake of fibre
suspension of the diet

Keturtest negative: dietary error

(sugar consumption greater than Correct dietary errors
allowed) Reassure the patient.
Less weight loss Clinical examination
Keturtest positive: possible S.D.M. Fibromanna
than predicted Keturtest
hormonal fluid retention. and/or S.D.M. Draincell
Constipation. Excessiveintake
of food and/or condiments (oil)

11
 MACRO- AND MICRO-NUTRIENTS IN THE S.D.M. DIET

Macro- and micro-nutrients in the S.D.M. diet

Carbohydrates

T
he S.D.M. protocol is designed to provide about 50-70 g/day of carbohydrates, which leads, in order, to lowering
the levels of insulin and reducing its anti-lipolytic activity. This is important to ensure a lipolytic process (and therefore
weight loss) that is constant and moderate, as well as stable ketogenesis, useful for eliminating hunger pangs and for
conferring a feeling of well-being during the diet.
The amount of carbohydrates in the protocol is also essential to providea supply of energy to the gluco-dependent cells
that do not contain mitochondria (red blood cells, adrenal cells) (Pezzana, Amerio et al. 2014, EFSA Panel on Dietetic Products
Nutrition andAllergies 2015).
The daily intake should not, however, exceed 1 +/-0,1 g/kg of ideal weight. Higher values inhibit ketogenesis and cancel
the anorectic effect.
The carbohydrates eaten during the dietary therapy can be complex (fibre) or simple, present in vegetables and S.D.M.
products themselves. In order to control the daily glucose intake, S.D.M. proposes a list of vegetables with a low
carbohydrate content (group 1), which the patient can consume at will, and a second list (group 2) of those that should
be consumed in only limited quantities.

Proteins

T
he S.D.M. diet is classified among normo-protein protocols (0.9-1.4 g/kg of ideal weight, table 1) (Pezzana, Amerio et
al. 2014, EFSAPanel on Dietetic Products Nutrition and Allergies 2015). S.D.M. products are made using high biological
value proteins all from the European foodchain.

BMI Weight REE Mifflin Min. Max.

Factor (b)
(Kg/m2) (Kg) (Kcal/die) (a) (g/die) (c) (g/die) (d)
22 (reference subject) 69 1901 1.00 57 115
25 78 1694 1,06 61 121
27,5 86 1773 1.11 63 127
MAN 30 94 1851 1,16 66 132
(Age 40, height 177 cm) 35 110 2008 1,25 72 144
40 125 2164 1,35 77 155
45 141 2321 1,45 83 166
50 157 2478 1,55 89 177
22 (reference subject) 58 1238 1,00 48 96
25 66 1322 1,07 51 103
27,5 73 1388 1,12 54 108
WOMAN 30 80 1455 1,18 57 113
(Age 40, height 163 cm) 35 93 1588 1,28 62 123
40 106 1721 1,39 67 134
45 120 1853 1,50 72 144
50 133 1986 1,60 77 154
(a) : Resting Energy Expenditure Kcal/die:
Men= (weight in kg x 10) + (height in cm x 6.25) - (age x 5) + 5; Women= (weight in kg x 10) + (height in cm x 6.25) - (age x 5) - 161.
(b) : REE BMI obese or overweight subject/ REE BMI normal reference weight subject.
(c) : 0.83 g/Kg reference body weight (BMI 22 Kg/m2 ) per day x factor.
(d) : 1.66 g/Kg reference body weight (BMI 22 Kg/m2 ) per day x factor.

Table 1. Minimum and maximum recommended protein intake in obese patients about 40 years old according to the EFSA 2015 (EFSA Panel on Dietetic
Products Nutrition and Allergies 2015).

12
 MACRO- AND MICRO-NUTRIENTS IN THE S.D.M. DIET

Lipids

T
he S.D.M. protocol is designed to include indispensable integration with extra virgin olive oil (10 grams,
corresponding to about 2 teaspoons), a source of essential fatty acids. This lipid intake is also helpful for promoting
good biliary function (Pezzana, Amerio et al. 2014, EFSA Panel on Dietetic Products Nutrition and Allergies 2015).
Complementary intake of S.D.M. OMEGA 3 is also proposed, since this helps to optimise the catabolism of triglycerides
and, at the same time, has a protective effect on the cardiovascular system.

UNICOMPLEX
Ingredients per dose (2 sachets) RDA / dose

I
t is an indispensable part of the S.D.M. protocol to Potassium 2000 mg 100
supplement the micro-elements, present in the vegetables Calcium 800 mg 100
allowed, by using S.D.M. UNICOMPLEX, a unique supplement Magnesium 375 mg 100
that contains a full complement of mineral salts and vitamins. Zinc 10 mg 100
Manganese 2 mg 100
Of the possible side effects that may occur during the S.D.M.
Copper 1 mg 100
dietary therapy, 95% are due to inadequate supplementation
of micro-nutrients. A ketogenic diet does, in fact, cause a Iodine 150 mcg 100
physiological increase in the renal excretion of mineral salts Selenium 55 mcg 100
(potassium, sodium, calcium, magnesium), which passively Chrome 40 mcg 100
follow the renal clearance of ketone bodies.
Vitamin C 80 mg 100
Excluding some macronutrients that are a source of mineral Vitamin PP 16 mg 100
salts from the daily diet can contribute to further reducing the Vitamin E 12 mg 100
basic reserves. Pantothenic acid 6 mg 100
Guaranteeing the correct supply of mineral salts and vitamins Vitamin B2 1,4 mg 100
is essential in order to maintain optimal cell function: for this
Vitamin B6 1,4 mg 100
reason, the S.D.M. UNICOMPLEX completely covers the daily
Vitamin B1 1,1 mg 100
requirements of all the main micro-nutrients (table 2).
Vitamin A 800 mcg 100
Folic acid 200 mcg 100
Table 2. Micro-nutrient formulation of S.D.M. UNCOMPLEX. Vitamin B8 50 mcg 100
Vitamin D 5 mcg 100
Vitamin B12 2,5 mcg 100

Fluid intake

I
t is recommended that the patient drinks at least 2 litres of water per day, which can be in the
form of unsweetened infusions, since this is indispensable to compensate for the increased
requirement during the dietary therapy (Pezzana, Amerio et al. 2014, EFSA Panel on Dietetic
Products Nutrition and Allergies 2015).

13
 MANAGEMENT OF THE PATIENT

Management of the patient

First appointment

I
n the field of nutrition, it is fundamental that a relationship of mutual trust is
established between the patient and the care professional. To this end, it
is essential to identify what has motivated the patient to start a diet and,
consequently, his or her expectations about it. A good initial approach leads
to greater compliance both in the short-term and in the long-term, which,
together with the efficacy and simplicity of management of the protocol,
ensures clinical success.
During the first interview, it is important to assess:

Medical history and evaluation of laboratory parameters: blood

count, blood glucose, blood urea nitrogen, uric acid, ALT, AST,
serum HDL-LDL cholesterol level, creatinine, Na-K electrolyte
balance
Anyongoing medication use,
Weight trends over time,
Eating habits,
General anthropometric values: weight, height, circumferences, skinfolds,
impedance analysis.

Based on the clinical and individual needs of the patient, a personalised S.D.M. diet is prescribed: this can be administered
in the classic or mitigated form (see next chapter).

Advice: faced with a severely overweight patient, it is important not to make the subject feel guilty and to propose
reasonably attainable intermediate objectives. It is advisable to fix the date of the second follow-up appointment 10-15
days after the first appointment, to ensure the patients real compliance and proper management of the protocol and to
evaluate the first results.

Subsequent appointments

I
t is suggested that follow-up visits are performed on a monthly basis, although
they can be more or less frequent at the discretion of the care professional.
If ketogenesis is maintained for a prolonged period, it is advisable to repeat the
blood-biochemistry analyses.

The follow-up visits are used to evaluate the results achieved

byre-analysing the anthropometric values and to discuss
any problems arising during the first period of the
diet, so as to strengthen the relationship between
the patient and the care professional.

14
 MANAGEMENT OF THE PATIENT

The S.D.M. dietary therapy

THE ATTACK PHASE

The classic diet

T
he S.D.M. protocol includes a first phase in which all the meals are replaced by S.D.M. products, associated with
vegetables with a low content of carbohydrates. It is essential to provide supplementary trace elements, mineral salts
and vitamins. S.D.M. has developed a specific supplement for this purpose, which simplifies the management for
both the nutritionist and the patient: S.D.M. UNICOMPLEX.

Use the following table to determine the number of daily meals :

Height in cm <160 160-170 170-180 >180

Women 3-4 meals 4 meals 4-5 meals 5 meals
Men 5 meals 5 meals 6 meals 6-7 meals

Supplementation:
UNICOMPLEX: 2 sachets/day (table 2), indispensable.
Omega 3: 2 capsules/day, optional, promotes the catabolism of triglycerides and lowers cardiovascular risk,
Fibromanna: 1 sachet/day, optional, promotes intestinal transit,
Probio (lactic ferments): 2 capsules/day, optional, rebalances the intestinal flora,
For women, Draincell: 2 caps in 1 litre of water, optional, in the case of water retention.

Vegetables without restriction:

Salads: Lettuce, Corn salad, Belgian endive, Rocket,
Chicory, Endive, Escarole, Treviso salad, Red and
green radicchio.
Cabbages: Radish, Cauliflower.
Leafy vegetables: Chard, Spinach, Celery, Turnip
greens.
Cucumber.
Mushrooms: Champignon, Caesar, Boletus.
Zucchini, zucchini flowers.
Cardoon. FOODS ALLOWED:
Zero/low calorie drinks
Unsweetened tea/coffee
Vegetables to limit Unsweetened infusions
(maximum 180g/die): Herbs, aromatic plants, spices and powdered
Cabbages: Broccoli, Cabbage, Sprouting broccoli, aromas
Romanesco, Headed cabbage, Savoy cabbage,
Chinese cabbage.
Fennel MOST COMMON MISTAKES:
Sweetened tea/coffee
Recommended physical activity: Barley coffee
Moderate aerobic activity, such as walking Fruit-based low calorie drinks;
30-45 minutes a day. Supplements other than S.D.M. UNICOMPLEX
which contain assimilablesugars;
Consumption of unpermitted vegetables.

15
 LA TERAPIA DIETETICA S.D.M.

The classic diet

EXAMPLE DAY:

Alternatives for Breakfast:

S.D.M. Cappuccino
S.D.M. Zwieback with 2/3 teaspoons of S.D.M.low calorie jam/hazelnut spreadand coffee
S.D.M. Shortbreadwith tea
S.D.M. Sea biscuitswith tea
S.D.M. Milk cornflakes
S.D.M. Pancake

Alternatives for the Mid-morning snack:

S.D.M. Bar
S.D.M. Wafer
S.D.M. Shortbread
S.D.M. Yoghurt-tasting drink
S.D.M. Stuzzichelle

AlternativesforLunch (associated with vegetables):

S.D.M. Pasta carbonara

S.D.M. Cream soup.
S.D.M. Focaccia with vegetables
S.D.M. Readymade meals

Alternatives for the Mid-afternoon snack:

S.D.M. Macaroons
S.D.M. Hot chocolate
S.D.M. Readymade puddings
S.D.M. Procrockbiscuit
S.D.M. Soya nuts
S.D.M. Peach tea

AlternativesforDinner (associated with vegetables):

S.D.M. Omelette
S.D.M. Risotto
S.D.M. Breadsticks with salad
S.D.M. Vegetable soup
S.D.M. Soup

16
 LA TERAPIA DIETETICA S.D.M.

The mitigated diet

T
he S.D.M. protocol offers the possibility of following the diet while including a serving of meat, fish or eggs, during
one of the main meals in replacement of an S.D.M. food, together with vegetables with a low carbohydrate content.
This allows ketogenesis to be triggered, with resulting weight loss, and at the same time grants the patient a discrete
conviviality. The mitigated diet can also be considered the phase following the classic diet. Supplementation of trace
elements, mineral salts and vitamins (S.D.M. UNICOMPLEX) is essential in this protocol, too.

Use the following table to determine the number of daily meals:

Height in cm <160 160-170 170-180 >180

Women 2-3 meals 3 meals 4 meals 4-5 meals
Men 4 meals 4 meals 5 meals 5-6 meals

Supplementation:
UNICOMPLEX: 2 sachets/day (table 2), indispensable.
Omega 3: 2 capsules/day, optional, promotes the catabolism of triglycerides and lowers cardiovascular risk,
Fibromanna: 1 sachet/day, optional, promotes intestinal transit,
Probio (lactic ferments): 2 capsules/day, optional, rebalances the intestinal flora,
For women, Draincell: 2 caps in 1 litre of water, optional, in the case of water retention.

Free meal: Vegetables to limit (maximum 180g/die):

Animal proteins: Solenaceae: Aubergine, Tomato, Pepper
Lean beef: Tenderloin, Sirloin, Topside, Silverside, Artichoke, Asparagus, Brussels sprouts, String beans,
Rump, Lean thick flank, Lean beef-burger, Carpaccio. Boiled yellow squash, Turnip,
White meat: Chicken, Turkey, Rabbit. Cabbages: Broccoli, Cabbage, Sprouting broccoli,
Cold cuts: Bresaola, Raw ham with fat removed, Romanesco, Headed cabbage, Savoy cabbage,
Lean fish: Bream, Bogue, Snapper,Smooth- Chinese cabbage, Brussels sprouts
hound, Sole, Seabass, Tub gurnard, Perch, Monkfish, Leafy vegetables: Chard, Spinach, Celery, Turnip
Branzino, Gilthead, Mullet, Trout, John Dory,Squid, tops, Fennel, Leek
Octopus, Cuttlefish, Musky octopus, Cod, Soya bean sprouts.
Shellfish: Prawns, Lobster, Crayfish, Slipper lobster,
Semi oily fish: Anchovy, Sardine, Tuna, Swordfish, Recommended physical activity:
Carp, Tench. moderate aerobic activity, such as walking 30-45
minutes a day.
FOODS ALLOWED:
Vegetables without restriction: Zero/low calorie drinks
Salads: Lettuce, Corn salad, Belgian endive, Rocket, Unsweetened tea/coffee
Chicory, Endive, Escarole, Treviso salad, Red and Unsweetened tisanes
green radicchio Herbs, aromatic plants, spices and powdered aromas
Cabbages: Radish, Cauliflower
Leafy vegetables: Chard, Spinach, Celery, Turnip MOST COMMON MISTAKES:
greens Sweetened tea/coffee
Cucumber, Barley coffee
Mushrooms: Champignon, Caesar, Bolelus Fruit-based low calorie drinks;
Zucchini, Zucchini flowers, Supplements other than S.D.M. UNICOMPLEX
Cardoon. which containassimilablesugars;
Consumption of unpermitted vegetables
17
 LA TERAPIA DIETETICA S.D.M.

The mitigated diet

EXAMPLE DAY:

Alternatives for Breakfast

S.D.M. Cappuccino S.D.M.

S.D.M. Zwieback with 2/3 teaspoons of S.D.M. low calorie jam/hazelnut spread and coffee
S.D.M. Shortbread with tea
S.D.M. Sea biscuits with tea
S.D.M. Milk cornflakes
S.D.M. Pancake

Alternatives for the Mid-morning snack:

S.D.M. Bar
S.D.M. Wafer
S.D.M. Shortbread
S.D.M. Yoghurt-tasting drink
S.D.M. Stuzzichelle

Alternatives for Lunch/Dinner (associated with vegetables):

S.D.M. Pasta carbonara

S.D.M. Cream soup.
S.D.M. Focaccia with vegetables
S.D.M. Readymade meals

Alternatives for the Mid-afternoon snack:

S.D.M. Macaroons
S.D.M. Hot chocolate
S.D.M. Readymade puddings
S.D.M. Procrock biscuit
S.D.M. Soya nuts
S.D.M. Peach tea

18
 LA TERAPIA DIETETICA S.D.M.

The transition
Introduction

The transition is an extremely important phase of the S.D.M. di-

etary protocol as it allows stabilisation of the weight reached,
thanks to the gradual and careful increase of the daily calorie
intake.

Precisely because of its strategic role, the transition phase

must be undertaken both by those who have achieved
their goal weight and by those who wish to take a break or
suspend the diet itself.

The scientific rationale of the transition phase has been

determined based on clinical experience, gained over the
years, and evidence in the international literature and can
be summarised in the following points:

The metabolic response of the body to the

calorie restriction of aVLCKD and the consequent
need for a gradual increase in calories.

It is known that, as a result of any calorie restriction, the basal

metabolism (BM) of an individual tends to decrease gradually. The
reduction of the BM can be between 17% and 25% and this effect
becomes more significant as the entity and duration of the calorie
restriction increase (Leibel, 1995).

According to a similar phenomenon it is easy to understand that, at the end of a VLCKD

protocol, when the patient resumes a diet with a significantly much higher calorie intake, one of
the bodys priorities would be immediate restoration of the reserves of adipose tissue (return to set-point) (Lidner and
Blackburn 1976 Keesey1997, Blackburn 2007).

For this reason it is essential to re-introduce the foods, and therefore calorie intake, gradually, so as to induce an
equally gradual and proservingal increase in the subjects basal calorie consumption (Gripeteg, Torgerson et al. 2010). As
demonstrated by the study by Gripeteget al. the duration of the transition phase and the graduality of calorie increase,
together, enable achievement of the bestmedium- and long-term results with regards to both weight maintenance
and some clinical parameters.

In this study, at the end of a VLCKD protocol (<800 calories/day) lasting 12 weeks, two groups of patients who achieved a significant percentage
reduction of weight (about - 18%) began a transition phase of different duration.
In the long-term (52 weeks), the group of 65 patients that followed a transition phase lasting 6 weeks maintained the results achieved with the
VLCKD, compared to the group of 58 patients who followed a transition phase of only 1 week (p = 0.006 ).
In the same study, the patients in the group that followed a transition period lasting 6 weeks maintained, over time, a significant reduction
in waist circumference and systolic and diastolic blood pressure, compared to patients who followed a transition phase lasting just 1 week
(Gripeteg, Torgerson et al. 2010).

19
In the light of the foregoing considerations, it is advised that the transition phase lasts as long as the phase of weight
reduction and that it is divided into four steps.
Each step involves an increase of about 200 Kcal (Figure 3), achieved by:

A gradual reduction in the number of S.D.M. protein foods;

An increase in the proserving of carbohydrates, using foods with a low glycaemic index (GI);

Introduction of foods present in the Mediterranean diet;

Gradual reduction of micro-nutrient supplementation.

SDM diet Decrease of 17 to 25% in the BM 1800 cal.

600-800 cal. during active weight loss

tion
he transi
during t
the BM
re ase in
e inc
ro g ressiv
P

Step Step Step Step

1 2 3 4
Figure 3. In a patient who has a hypothetical calorie consumption of 1800 Kcal/day, the very low calorie intake of the attack phase causes a reduction in
calorie consumption which, according to the literature data and depending on the duration of the weight loss, can be as much as 25%. Weight loss is
nevertheless still guaranteed by the low-calorie and reduced carbohydrate supply of the SDM protocol. The progressive increase in calories, provided in
each of the four steps of the transition phase, gradually raises the BM.

The importance of an adequate protein supply

During the different steps of the transition phase it is critical that the protein intake is adequate for the needs of the
individual subject in order for his or her lean mass to be safeguarded and so that the satiating effect of proteins promotes
the patients good compliance until completion of the dietary protocol.

The observations of MargrietWesterterp-Plantenga, a leading international expert on the subject, confirm that, at the end
of a VLCKD protocol in which there has been a weight loss of 5-10%, a significant supply of proteins in the transition phase
and during maintenance affords better stabilisation of results in the medium- and long-term (Westerterp-Plantenga 2004,
Lejeune, Kovacs et al. 2005).

20
 In the above study, at the end of a VLCKD protocol (<800 calories/day) lasting 4 weeks, two groups of previously randomised patients, after
having obtained a significant reduction in percentage of body weight (between 5% and 10% ), underwent a transition phase and maintenance
with two diets containing different percentages of protein.
Over a period of 12 months, compared to the group of 60 patients who followed a transition phase with a protein content of 15% of the daily
calorie intake, the group of 53 patients who followed a transition phase with a protein content of 18% of the daily calorie intake had:

less weight gain over time;

better body composition (higher percentage of lean mass and lower percentage of body fat);
a smaller abdominal circumference;
a more constant feeling of satiety;
a lower respiratory quotient.

(Westerterp-Plantenga 2004).

In order to ensure optimal protein intake, without increasing the calorie content of each step excessively, the protocol for
the transition phase includes the daily consumption of a defined number of S.D.M. protein foods, established on the
basis of the course of the VLCKD.

The importance of the daily number of meals

Another interesting aspect, which can influence weight gain, is the number of meals in a day. Investigations carried out
so far have shown a lower risk of metabolic syndrome when calorie intake is distributed through the day in four meals
rather than in three.

For example, in a study by Chapelotof percentage changes in fat mass and plasma concentrations of leptin in relation to the number of meals
in the day, it was seen that the subjects who passed from 4 to 3 daily meals had increases of both fat mass and the level of circulating leptin.
The passage, in the same subjects, from 3 to 4 daily meals helpedto reduce fat mass and lower leptin levels (Chapelot, 2006).

In a similar study, Fabry showed the different incidence of clinical aspects of the metabolic syndrome betweena group of patients receiving
three or fewer meals in a day compared to a group receiving five or more than five daily meals.
The incidences of: excess weight, high cholesterol and insulin resistance were higher among the subjects receiving three meals (or even fewer)
in a day. In contrast, the subjects who received five or more meals in a day had significantly lower incidence of these conditions and a higher
frequency of laboratory values within the normal range (Fabry, 1994).

In the light of the above considerations, it is recommended that the patient receives at least five daily meals, so as to
divide the calorie supply of the macronutrients appropriately.

The importance of the daily glycaemic load

With respect to the calorie intake of carbohydrates, the concept of avoiding carbohydrates with a high glycaemic index
remains fundamental (Brand-Miller, Holt et al., 2002, Barclay, Petocz et al. 2008 Vesely and DeMattia 2014), with particular
attention to the overall glycaemic load of the diet.

This aspect enables insulin secretion to be kept under control, thus avoiding massive reactivation of lipo-synthesis,
which underlies the increase in adipose tissue. According to most experts, a total daily glycaemic load of less than 80
would significantly reduce weight gain after the slimming programme and reduce the risk of insulin resistance in the
maintenance phase (Brand-Miller 2008, Afaghi 2012). The transition phase therefore incorporates a gradual reintroduction
of carbohydrates, choosing foods with a low glycaemic index and moderating their amount, so as to reduce the glycaemic
load of each meal and not exceed the recommended daily total glycaemic load (Vesely and DeMattia 2014).

21
 LA TERAPIA DIETETICA S.D.M.

The 4 steps of the transition

Step I Step II Step III Step IV

Introduction of fruit Introduction of dairy products Introduction of oily seeds Increase of calories through the
+ + + same foods introduced in the
Introduction of meat/fish/vegetable Introduction of cereals Introduction of legumes preceding steps
protein foods at lunch and dinner

Transition 1stStep
Introduction of fruit

Introduction of a 2nd dish at lunchand dinner

FRUIT:
Fresh and ideally in season, 1 serving of 100-150 g *.
*Theserving of fruitcan be replaced by centrifuged fruit juice or fruit extract.

2nd DISH:
Meat (1 servingof about 100-150 g).
Lean red (the recommended amount is 1 servingper week): tenderloin, sirloin, topside, silverside, rump, lean thick flank,
lean beef-burger, carpaccio.
White: chicken, turkey, rabbit.
Cold cuts (1 serving of about 60 g): bresaola, cooked ham, raw ham or bacon with the fat removed.

Fish (1 servingof about 150-200 g).

Lean: Bream, Bogue, Snapper,Smooth-hound, Sole, Seabass, Tub gurnard, Perch, Monkfish, Branzino, Gilthead, Mullet,
Trout, John Dory, Cod.
Oily: Anchovy, Sardine, Tuna, Salmon (including smoked salmon), Swordfish, Carp, Tench.
Molluscs: Squid, Octopus, Cuttlefish, Musky octopus,
Shellsh: Prawns, Lobster, Crayfish, Slipper lobster.

Eggs (2 per serving): maximum 2 servings in a week.

Vegetable-based protein foods (1 servingof about 150-200 g): tofu, seitan, soya, tempeh.

22
 LA TERAPIA DIETETICA S.D.M.

Transition 2nd step

Introduction of dairy products

Introduction of cereals

LOW-FAT CHEESES (1 serving of about 80-100 g):

Ricotta (cowsmilk / ewesmilk), primo sale, cottage cheese.

CEREALS:
Low GI S.D.M. tagliatelle, spelt, wheat, barley, wholegrain rice, basmati rice, black rice, amaranth, buckwheat*, quinoa*.
Low-carbohydrate wholemeal bread made of rye or spelt, biscuits with a low GI, crispbread.

*although these are not cereals, from a purely nutritional point of view, they can be considered analogues of cereals.

Transition 3rd step

Introduction of oily seeds

Introduction of legumes

OILY SEEDS:
Walnuts, hazelnuts, almonds

LEGUMES:
Lentils, beans, chickpeas, peas, broad beans, soya beans, edamame.

Transition 4th step

Calorie increase with the same foods as those introduced during the preceding steps.

23
 LA TERAPIA DIETETICA S.D.M.

Transitionphase following a weight- losing diet

with 3 meals
First step of the transition
Breakfast Mid-morning snack Lunch Mid-afternoon snack Dinner

A 2nd dish: all the foods in the

A 2nd dish: all the foods in the
permitted list are allowed
permitted list are allowed
except low-fat cheeses
except low-fat cheeses
+
1 SDM food +
1 servingof unrestricted
+ 1 serving of fruit 1 servingof unrestricted
vegetables
1 serving of fruit vegetables +
+
condiment:1 tablespoon of
condiment: 1 tablespoon of
extra virgin olive oil
extra virgin olive oil

Second step of the transition

Breakfast Mid-morning snack Lunch Mid-afternoon snack Dinner

125 g of yoghurt / 1 egg / 2

slices of lean cold cuts / 50 g
of feta / A 2nd dish A 2nd dish
1 SDM transition food + +
SDM food
+ 1 servingof unrestricted 1 servingof unrestricted
+
1 serving of fruit vegetables 1 serving of fruit vegetables
1 serving of fruit
+ + +
2 slices of wholemeal bread condiment: 1 tablespoon of condiment: 1 tablespoon of
(type, sandwich loaf ) / low GI extra virgin olive oil extra virgin olive oil
biscuit /
30 g of muesli

Third step of the transition

Breakfast Mid-morning snack Lunch Mid-afternoon snack Dinner
1 serving of 70 g of cereal
+
A 2nddish
125 g of yoghurt /1 egg / 2
+
slices of lean cold cuts / 50 g
1 serving di unrestricted A 2nddish
of feta / 1 SDM transition food
vegetables +
+
1 serving of fruit / 20 g + 1 servingof unrestricted
1 serving of fruit
of almonds, walnuts or condiment: 1 tablespoon of 1 serving of fruit vegetables
+
hazelnuts extra virgin olive oil +
2 slices of wholemeal bread
condiment: 1 tablespoon of
(type, sandwich loaf )/ low GI
NB: the food in the 2nd extra virgin olive oil
biscuit / 30 g of muesli
dish and the cereal can be
replaced by a serving of
legumes (100 g, cooked
weight)

Fourth step of the transition

Breakfast Mid-morning snack Lunch Mid-afternoon snack Dinner
1 serving da 70 g of cereal
+
A 2nddish
125 g of yoghurt/ 1 egg / 2 + A 2nddish
slices of lean cold cuts / 50 g 1 servingof unrestricted +
of feta /1 SDM transition food vegetables 1 servingof cereal 40 g
+ 1 serving of fruit / 20 + +
1 serving of fruit g almonds, walnuts or condiment: 1 tablespoon of 1 serving of fruit 1 servingof unrestricted
+ hazelnuts extra virgin olive oil vegetables
3 slices of wholemeal bread +
(type, sandwich loaf )/ low GI NB: the food in the 2nd condiment: 1 tablespoon of
biscuit / 50 g of muesli dish and the cereal can be extra virgin olive oil
replaced by a serving of
legumes (100 g, cooked
weight)

24
 LA TERAPIA DIETETICA S.D.M.

Transition phase following a weight- losing diet

with 4 meals
First step of the transition
Breakfast Mid-morning snack Lunch Mid-afternoon snack Dinner

A 2nd dish: all the foods in the A 2nd dish: all the foods in the
permitted list are allowed permitted list are allowed
except low-fat cheeses except low-fat cheeses
1 SDM food
+ +
+
SDM food 1 servingof unrestricted SDM food 1 servingof unrestricted
1 serving of fruit
vegetables vegetables
+ +
condiment: 1 tablespoon of condiment: 1 tablespoon of
extra virgin olive oil extra virgin olive oil

Second step of the transition

Breakfast Mid-morning snack Lunch Mid-afternoon snack Dinner

A 2nddish
125 g of yoghurt / 1 egg / 2
+
slices of lean cold cuts / 50 g A 2nddish
1 servingof unrestricted
of feta / 1 SDM transition food +
vegetables
+ SDM food SDM food 1 servingof unrestricted
+
1 serving of fruit + + vegetables
condiment: 1 tablespoon of
+ 1 serving of fruit 1 serving of fruit +
extra virgin olive oil
2 slices of wholemeal bread condiment: 1 tablespoon of
+
(type, sandwich loaf )/low GI extra virgin olive oil
2 slices of wholemeal bread
biscuit / 30 g of muesli
(type, sandwich loaf

Third step of the transition

Breakfast Mid-morning snack Lunch Mid-afternoon snack Dinner
1 serving da 70 g of cereal
+
A 2nddish
125 g of yoghurt/1 egg / 2 +
slices of lean cold cuts / 50 g 1 servingof unrestricted
A 2nddish
of feta / 1 SDM transition food vegetables
+
+ 1 serving of fruit / 20 g + SDM food
1 servingof unrestricted
1 serving of fruit di almonds, walnuts or condiment: 1 tablespoon of +
vegetables +
+ hazelnuts extra virgin olive oil 1 serving of fruit
condiment: 1 tablespoon of
2 slices of wholemeal bread
extra virgin olive oil
(type, sandwich loaf )/ low GI NB: the food in the 2nd
biscuit / 30 g of muesli dish and the cereal can be
replaced by a serving of
legumes (100 g, cooked
weight)

Fourth step of the transition

Breakfast Mid-morning snack Lunch Mid-afternoon snack Dinner
A 2nddish
+
1 servingof cereal 50 g
125 g of yoghurt / 1 egg / 2 1 serving da 60 g of cereal
+
slices of lean cold cuts / 50 g +
1 servingof unrestricted
of feta / 1 SDM transition food A 2nddish
vegetables +
+ 1 serving of fruit / 20 g + SDM food
condiment: 1 tablespoon of
1 serving of fruit di almonds, walnuts or 1 servingof unrestricted +
extra virgin olive oil
+ hazelnuts vegetables 1 serving of fruit
3 slices of wholemeal bread +
NB: the food in the 2nd
(type, sandwich loaf ) / low GI condiment: 1 tablespoon of
dish and the cereal can be
biscuit / 40 g of muesli extra virgin olive oil
replaced by a serving of
legumes (150 g, cooked
weight)

25
 LA TERAPIA DIETETICA S.D.M.

Transition phase following a weight- losing diet

with 5 meals
First step of the transition
Breakfast Mid-morning snack Lunch Mid-afternoon snack Dinner

A 2nd dish: all the foods in the

A 2nd dish: all the foods in the
permitted list are allowed
permitted list are allowed
except low-fat cheeses
except low-fat cheeses
1 SDM food +
+
+ 1 servingof unrestricted
SDM food 1 servingof unrestricted SDM food
1 serving of fruit vegetables +
vegetables
condiment: 1 tablespoon of
+
extra virgin olive oil
condiment: 1 tablespoon of
+
extra virgin olive oil
SDM food

Second step of the transition

Breakfast Mid-morning snack Lunch Mid-afternoon snack Dinner

A 2nddish
125 g of yoghurt / 1 egg / 2 A 2nddish
+
slices of lean cold cuts / 50 g +
1 servingof unrestricted
of feta / 1 SDM transition food 1 serving of unrestricted
vegetables
+ SDM food SDM food vegetables
+
1 serving of fruit + + +
condiment: 1 tablespoon of
+ 1 serving of fruit 1 serving of fruit condiment 15g of extra virgin
extra virgin olive oil
2 slices of wholemeal bread olive oil
+
(type, sandwich loaf )/low GI +
2 slices of wholemeal bread
biscuit / 30 g of muesli SDM food
(type, sandwich loaf )

Third step of the transition

Breakfast Mid-morning snack Lunch Mid-afternoon snack Dinner
1 serving of 70 g of cereal
+
a 2nddish
125 g of yoghurt / 1 egg / 2 +
A 2nddish
slices of lean cold cuts / 50 g 1 servingof unrestricted
+
of feta / 1 SDM transition food vegetables
1 servingof unrestricted
+ 1 serving of fruit / 20 g + SDM food
vegetables +
1 serving of fruit di almonds, walnuts or condiment: 1 tablespoon of +
condiment: 1 tablespoon of
+ hazelnuts extra virgin olive oil 1 serving of fruit
extra virgin olive oil
2 slices of wholemeal bread
+
(type, sandwich loaf )/low GI NB: the food in the 2nd
SDM food
biscuit / 30 g of muesli dish and the cereal can be
replaced by a serving of
legumes (100 g, cooked
weight)

Fourth step of the transition

Breakfast Mid-morning snack Lunch Mid-afternoon snack Dinner
A 2nddish
+
1 servingof cereal 50 g
125 g of yoghurt / 1 egg / 2 1 servingof 80 g of cereal
+
slices of lean cold cuts / 50 g +
1 servingof unrestricted
of feta / 1 SDM transition food a 2nddish
vegetables +
+ 1 serving of fruit / 20 g + SDM food
condiment: 1 tablespoon of
1 serving of fruit di almonds, walnuts or 1 servingof unrestricted +
extra virgin olive oil
+ hazelnuts vegetables 1 serving of fruit
3 slices of wholemeal bread +
NB: the food in the 2nd
(type, sandwich loaf )/ low GI condiment: 1 tablespoon of
dish and the cereal can be
biscuit / 50 g of muesli extra virgin olive oil
replaced by a serving of
legumes (150 g, cooked
weight)

26
 LA TERAPIA DIETETICA S.D.M.

Transition phase following a weight- losing diet

with 6-7 meals
First step of the transition
Breakfast Mid-morning snack Lunch Mid-afternoon snack Dinner

A 2nd dish: all the foods in the

A 2nd dish: all the foods in the
permitted list are allowed
permitted list are allowed
except low-fat cheeses
except low-fat cheeses
+
1 SDM food +
1 servingof unrestricted
+ SDM food SDM food 1 servingof unrestricted
vegetables
1 serving of fruit vegetables +
+
condiment: 1 tablespoon of
condiment: 1 tablespoon of
extra virgin olive oil
extra virgin olive oil
+
+
SDM food
SDM food

Second step of the transition

Breakfast Mid-morning snack Lunch Mid-afternoon snack Dinner

A 2nddish
125 g of yoghurt / 1 egg / 2
+ A 2nddish
slices of lean cold cuts / 50 g
1 servingof unrestricted +
of feta / 1 SDM transition food
vegetables 1 servingof unrestricted
+ SDM food SDM food
+ vegetables +
1 serving of fruit + +
condiment: 1 tablespoon of condiment: 1 tablespoon of
+ 1 serving of fruit 1 serving of fruit
extra virgin olive oil extra virgin olive oil
2 slices of wholemeal bread
+ +
(type, sandwich loaf/low GI
2 slices of wholemeal bread SDM food
biscuit / 30 g of muesli
(type, sandwich loaf

Third step of the transition

Breakfast Mid-morning snack Lunch Mid-afternoon snack Dinner
A 2nddish
+
1 servingof cereal 50 g
+
125 g of yoghurt / 1 egg / 2 1 serving da 70 g of cereal
1 servingof unrestricted
slices of lean cold cuts / 50 g +
vegetables +
of feta / 1 SDM transition food a 2nddish
condiment: 1 tablespoon of
+ 1 serving of fruit / 20 g + SDM food
extra virgin olive oil
1 serving of fruit di almonds, walnuts or 1 servingof unrestricted +
+
+ hazelnuts vegetables 1 serving of fruit
SDM food
2 slices of wholemeal bread +
(type, sandwich loaf/low GI condiment: 1 tablespoon of
NB: the food in the 2nd
biscuit / 30 g of muesli extra virgin olive oil
dish and the cereal can be
replaced by a serving of
legumes (100 g, cooked
weight)

Fourth step of the transition

Breakfast Mid-morning snack Lunch Mid-afternoon snack Dinner
A 2nddish
+
1 servingof cereal 50 g
125 g of yoghurt / 1 egg / 2 1 serving of 80 g of cereal
+
slices of lean cold cuts / 50 g +
1 servingof unrestricted
of feta / 1 SDM transition food a 2nddish
vegetables +
+ 1 serving of fruit / 20 g + SDM food
condiment: 1 tablespoon of
1 serving of fruit ofalmonds, walnuts or 1 servingof unrestricted +
extra virgin olive oil
+ hazelnuts vegetables 1 serving of fruit
3 slices of wholemeal bread +
NB: the food in the 2nd
(type, sandwich loaf / low GI condiment: 1 tablespoon of
dish and the cereal can be
biscuit / 60 g of muesli extra virgin olive oil
replaced by a serving of
legumes (150 g, cooked
weight)

27
 THE S.D.M. DIETARY THERAPY

Supplementation:
UNICOMPLEX: indispensable in the first three steps of the transition.
The recommended dose is 2 sachets during step 1, 1sachet during steps 2-3.
During step 4, supplementation with Unicomplex
is recommended at the discretion of the care professional.
Omega 3: 2 capsules/day, optional, promotes catabolism of triglycerides and lowers cardiovascular risk,
Fibromanna: 1 sachet/day, optional, promotes intestinal transit,
Probio (lactic ferments): 2 capsules/day, optional, rebalances intestinal flora,
For women Draincell: 2 caps in 1 litre of water, optional, in the case of water retention.

Unrestricted vegetables:
Lettuce, Corn salad, Belgian endive, Rocket, Chicory, Endive, Escarole, Treviso salad, Red
and green radicchio, Radish, Chard, Spinach, Celery, Turnip greens, Green peppers, Fennel,
Broccoli, Cauliflower, Cabbage, Sprouting broccoli, Romanesco, Headed cabbage, Savoy
cabbage, Chinese cabbage, Champignon mushrooms, Caesars mushrooms, Bolelus, Soya
sprouts, Zucchini, Zucchini flowers, Cucumber, Cardoon, Aubergine, Tomatoes, Yellow and red
peppers, Artichokes, Asparagus, Brussels sprouts, String beans, Yellow squash, Turnips, Dandelion.

Condiments:
Extra virgin olive oil: consume the amount presentedfor each step.
Spices: all dried spices, such as oregano, curry, thyme, laurel, etc., are allowed
On pasta: tomato sauce, pesto sauce, fishsauce.

Physical activity:
Regular physical activity is recommended: walking, cycling, swimming for at least 40-45 minutes. The physical exercise can be
intensified gradually during the various steps of the transition phase and can also include more vigorous activities such as running,
tone-up, aerobics, etc.

28
 THE S.D.M. DIETARY THERAPY

Maintenance

O
ver the years, numerous studies have examined the strategies for maintaining the results obtained with a VLCKD
dietary protocol in the medium- and long-term (Desjeux, Gernez-Lestradet et al. 1982, Romon, Edme et al. 1993,
Brand-Miller, Holt et al. 2002, OReardon, Ringel et al. 2004, Wing and Phelan 2005, Chapelot, Marmonier et al. 2006,
Thomas, Elliott et al. 2007, Livesey, Taylor et al. 2008, Paddon-Jones, Westman et al. 2008, Larsen, Dalskov et al. 2010, Larsen,
Dalskov et al. 2010).

These studies have shown that it is essential to:

Carry out moderate, aerobic physical activity regularly for 45-60 minutes.

At a metabolic level this causes:

- Reactivation of basal metabolism;

- Increased calorie consumption, mobilisation of fat mass;
- Preservation of lean body mass;
- Resolution of the phenomenon of insulin resistance, as well as more efficient utilisation of carbohydrates and
fats even at rest;
- Improvement in respiratory and cardio-circulatory efficiency, with rebalancing of blood pressure and
reduction of resting heart rate;
- Improvement of the lipid profile;
- Prevention of osteoporosis;
- Improvement of bowel function;
- Reduction of oxidative stress and improved mood and sleep quality.

Eat at least five servings of fruit and vegetables, since these are rich in fibre, vitamins, mineral salts and anti-oxidants.

Maintain a proper level of body fluid by drinking at least 1.5-2 litres of water each day.

Start the day with a balanced breakfast so that Ghrelin levels are kept under control, thereby reducing hunger
during the day (Foster-Schubert, Overduin et al. 2008).

Distribute the calorie requirements of the day in at least four meals, preferably respecting the following percentages:
breakfast 27%, lunch 36%, snack 13% and dinner 24%.

Eat food with a low glycaemic load and index.

Ensure that protein intake:

- Is not less than 20% of the total calorie requirements, in order to preserve lean mass;
- Is distributed evenly within each meal, to reduce its glycaemic load and have a greater satiating effect
(Chapelot, Marmonier et al. 2006, Tom 2009).

Reduce the overall contents of fats, particularly saturated fats, of animal origin, and hydrogenated ones, of vegetable
origin.

Respect the RDA for mineral salts, vitamins and trace elements.

29
 Conclusions

T
he effectiveness of the whole VLCKD protocol is closely
related to strict compliance with the various aspects of the
rationale governing the four steps of the transition phase.

The transition must be understood as a real nutritional re-

education, during which the patients, by following the entire
course, acquire a new awareness that allows them to make better
food choices in terms of carbohydrate and lipid content,while
restricting calorie intake.

In a VLCKD protocol, weight loss tends to remain constant because

of the particular characteristics of the diet: low calorie content
associated with reduced insulin stimulation.

At the end of the attack phase, the preserved lean body mass,
which is guaranteed by the optimal protein supply during the
phase of weight loss, and the progressive increase in calories, with
foods that have a low glycaemic load, in each of the four steps of
the transition phase,enable metabolism to return to appropriate
levels.

30
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Alberts, B., A. Johnson, J. Lewis, M. Raff, M. Roberts suppressed strongly by ingested proteins, weakly C. Allison, N. L. Rogers, N. S. Martino and A. J.
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