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Ketojenik Diyetlerin Obezite Tedavisindeki Etkinliği

Year 2023, Volume: 10 Issue: 1, 45 - 55, 23.06.2023

Abstract

Dünya Sağlık Örgütü'ne (WHO) göre, 1975'ten beri dünya çapında obezite prevalansı üç katına çıkmış ve epidemik ölçeğe ulaşmıştır. Obezitenin önlenmesi ve tedavisi; yeme alışkanlıkları, fiziksel aktivite ve davranış terapisini içeren yaşam tarzı değişikliklerine dayanmaktadır. Beslenme stratejileri olarak çeşitli diyet kalıpları kullanılmıştır ve son yıllarda da epilepsi için yardımcı bir tedavi olan ketojenik diyetlere ilgi gösterilmiştir. Ketojenik diyetlerde karbonhidrat oranı düşük tutularak beynin başlıca enerji kaynağı olan glikoz kullanımı yerine keton cisimcikleri kullanılmakta ve çeşitli mekanizmalar aracılığı ile iştah hormonları, mikrobiyota, vücut ağırlığı kaybı üzerinde etki göstermektedir. Bu derlemenin amacı, ketojenik diyetlerin iştah hormonları, mikrobiyota üzerindeki çeşitli mekanizmaları inceleyerek vücut ağırlığı kaybı ve yönetiminin sağlanmasına ilişkin güncel literatür bilgilerini incelemektir.

References

  • Küçük CK, Yıbar A. Popüler diyet akımlarının vücut ağırlığı ve sağlık üzerine etkileri. Akademik Gıda. 2021; 19(1): 98-107. doi: 10.24323/akademik-gida.927722.
  • World Health Organization. Obesity and Overweight. 2021. Available from: https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight [Erişim Tarihi: 12.10.2021].
  • Rosa DC, Lattanzi G, Taylor SF, Manfrini S, Khazrai YM. Very low calorie ketogenic diets in overweight and obesity treatment: effect on anthropometric parameters, body composition, satiety, lipid profile and microbiota. Obesity Research and Clinical Practice. 2020; 14(6), 491-503. doi: 10.1016/j.orcp.2020.08.009.
  • Deemer SE, Plaisance EP. Impact of Ketosis on appetite regulation – A review. Nutr Res. 2020; 77, 1-11. doi: 10.1016/j.nutres.2020.02.010.
  • Türkiye İstatistik Kurumu. Türkiye Sağlık Araştırması, 2019. 2020. Erişim Linki: https://data.tuik.gov.tr/Bulten/Index?p=Turkey-Health-Survey-2019-33661 [Erişim Tarihi: 12.12.2021].
  • Benelam B. Satiation, satiety and their effect on eating behaviour. Nutrition Bulletin. 2009; 34(2), 126-173. doi: 10.1111/j.1467-3010.2009.01753.x.
  • Gibson AA, Sainsbury A. Strategies to improve adherence to dietary weight loss interventions in research and real-world settings. Behav Sci. 2017; 7(3), 44. doi: 10.3390/bs7030044.
  • Koliaki C, Spinos T, Spinou M, Brinia, ME, Mitsopoulou D, Katsilambros N. Defining the optimal dietary approach for safe, effective and sustainable weight loss in overweight and obese adults. Healthcare. 2018; 6(3),73. doi; 10.3390/healthcare6030073.
  • Metin S. Epilepsi ve ketojenik diyetler. Tayfur M, editör. Beslenme ve Diyetetik Güncel Konular-4. 2.baskı. Ankara: Hatipoğlu Yayıncılık; 2021. S. 81-95.
  • Liu H, Yang Y, Wang Y, Tang H, Zhang F, Zhang Y, et al. Ketogenic diet for treatment of intractable epilepsy in adults: A meta-analysis of observational studies. Epilepsia. 2018; 3(1), 9–17. doi; 10.1002/epi4.12098.
  • Paoli A, Rubini AL, Volek JS, Grimaldi KA. Beyond weight loss: A review of the therapeutic uses of very-low carbohydrate (ketogenic) diets. Eur J Clin Nutr. 2013; 67(8), 789–96. doi; 10.1038/ejcn.2013.116.
  • Goday A, Bellido D, Sajoux I, Crujeiras AB, Burguera B, Garcìa Luna PP, et al. Short-term safety, tolerability and efficacy of a very low calorie ketogenic diet ınterventional weight loss program versus hypocaloric diet in patients with type 2 diabetes mellitus. Nutr Diabetes. 2016; 6(9), e230. doi; 10.1038/nutd.2016.36.
  • Calcaterra V, Verduci E, Pascuzzi MC, Magenes VC, Fiore G, Di Profio E, et al. Metabolic derangement in pediatric patient with obesity: The role of ketogenic diet as therapeutic tool. Nutrients. 2021; 13(8), 2805. doi; 10.3390/nu13082805.
  • van der Louw E, van den Hurk D, Neal E, Leiendecker B, Fitzsimmon G, Dority L, Thompson L, Marchió M, Dudzi´nska M, Dressler A, et al. Ketogenic diet guidelines for infants with refractory epilepsy. Eur J Paediatr Neurol 2016; 20(6), 798–809. doi; 10.1016/j.ejpn.2016.07.009.
  • Goswami JN, Sharma S. Current perspectives on the role of the ketogenic diet in epilepsy management. Neuropsychiatr Dis Treat. 2019; 15, 3273–3285. doi; 10.2147/NDT.S201862.
  • Drabinska N, Wiczkowski W, Piskula MK. Recent advances in the application of a ketogenic diet for obesity management. Trends in Food Science and Technology. 2021; 110, 28-38. doi; 10.1016/j.tifs.2021.01.080.
  • Ünalp A. Çocukluk çağı epilepsilerinde ketojenik diyet uygulamaları. İzmir Dr. Behçet Uz Çocuk Hast. Dergisi. 2017; 7(3), 169-177. doi; 10.5222/buchd.2017.169.
  • Kossoff EH, Zuhec-Kania BA, Amark PE, Ballaban-Gil KR, Christina Bergqvist AG, Blackford R, et al. Optimal clinical management of children reveiving the ketogenic diet: recommendations of the ınternational ketogenic diet study group. Epilepsia. 2009; 50, 304-317. doi; 10.1111/j.1528-1167.2008.01765.x.
  • Neal EG, Chaffe H, Schwartz RH, Lawson MS, Edwards N, Fitzsimmons G, et al. The ketogenic diet for the treatment of childhood epilepsy: Randomised controlled trial. Lancet Neurol. 2008; 7(6), 500-6. doi; 10.1016/S1474-4422(08)70092-9.
  • Furukawa K, Shigematus K, Iwase Y, Mikami W, Hoshi H, Nishiyama T, et al. Clinical effects of one year of chemotherapy with a modified medium-chain triglyceride ketogenic diet on the recurrence of stage ıv colon cancer. Journal of Japanese Society for Parenteral and Enteral Nutrition. 2018; 33(5), 1139-1146. doi; 10.11244/jspen.33.1139.
  • Veyrat-Durebex C, Reynier P, Procaccio V, Hergesheimer R, Corcia P, Andres CR, Blasco H. How can a ketogenic diet improve motor function? Front Mol Neurosi. 2018; 26;11, 15. doi; 10.3389/fnmol.2018.00015.
  • Paoli A. Ketogenic diet for obesity: friend or foe? Int J Environ Res Public Health. 2014; 11(2), 2092–107. doi; 10.3390/ijerph110202092.
  • Kumar S, Behl T, Sachdeva M, Sehgal A, Kumari S, Kumar A, Kaur G, Yadav HN, Bungau S. Implicating the effect of ketogenic diet as a preventive measure to obesity and diabetes mellitus. Life Sci. 2021; 264(1), 118661. doi; 10.1016/j.lfs.2020.118661.
  • O’Neill B, Raggi P. The ketogenic diet: Pros and cons. Atherosclerosis. 2020; 292, 119-126. doi; 10.1016/j.atherosclerosis.2019.11.021.
  • Gibson AA, Seimon RV, Lee CMY, Ayre J, Franklin J, Markovic TP, et al. Do ketogenic diets really suppress appetite? A systematic review and meta-analysis. Obes Rev. 2015; 16(1), 64–76. doi; 10.1111/obr.12230.
  • Coutinho SR, With E, Rehfeld JF, Kulseng B, Truby H, Martins C. The ımpact of rate of weight loss on body composition and compensatory mechanisms during weight reduction: A randomized control trial. Clin Nutr. 2018; 37(4), 1154–62. doi; 10.1016/j.clnu.2017.04.008.
  • Nymo S, Coutinho SR, Torgersen LH, Bomo OJ, Haugvaldstad I, Truby H, et al. Timeline of changes in adaptive physiological responses, at the level of energy expenditure, with progressive weight loss. Br J Nutr. 2018; 120(2), 141–9. doi; 10.1017/S0007114518000922.
  • Sumithran P, Prendergast LA, Delbridge E, Purcell K, Shulkes A, Kriketos A, et al. Ketosis and appetite-mediating nutrients and hormones after weight loss. Eur J Clin Nutr. 2013; 67(7), 759–64. doi; 10.1038/ejcn.2013.90.
  • Paoli A, Bosco G, Camporesi EM, Mangar D. Ketosis, ketogenic diet and food intake control: A complex relationship. Front Psychol. 2015;2; 6:27. doi; 10.3389/fpsyg.2015.00027.
  • Meidenbauer JJ, Ta N, Seyfried TN. Influence of a ketogenic diet, fish-oil and calorie restriction on plasma metabolites and lipids in C57BL/6J mice. Nutr Metab. 2014; 22;11, 23. doi; 10.1186/1743-7075-11-23.
  • De Luis, D., Domingo, J.C., Izaola, O., Cazanueva, F.F., Bellido, D., Sajaoux, I. 2016) Effect of DHA Supplementation in A Very Low-Calorie Ketogenic Diet in The Treatment of Obesity: A Randomized Clinical Trial. Endocrine, 54(1), 111-122.
  • Benani A, Troy S, Carmona MC, Fioramonti X, Lorsignol A, Leloup C, et al. Role for mitochondrial reactive oxygen species in brain lipid sensing: Redox regulation of food intake. Diabetes. 2007; 56(1), 152–160. doi; 10.1007/s12020-016-0964-z.
  • Caprio M, Infante M, Moriconi E, Armani A, Fabbri A, Mantovani G, et al. Very-low-calorie ketogenic diet (vlckd) in the management of metabolic diseases: Systematic review and consensus statement from the ıtalian society of endocrinology (SIE). J Endocrinol Invest. 2019; 42(11), 1365–86. doi; 10.1007/s40618-019-01061-2.
  • Falsaperla R, D’Angelo G, Pratico AD, Mauceri L, Barbagallo M, Pavone P, et al. Ketogenic diet for ınfants with epilepsy: A literature review. Epilepsy Behav. 2020; 112,107361. doi; 10.1016/j.yebeh.2020.107361.
  • Ni FF, Li CR, Liao JX, Wang GB, Lin SF, Xia Y, et al. The effects of ketogenic diet on the Th17/Treg cells ımbalance in patients with ıntractable childhood epilepsy. Seizure. 2016; 38, 17–22. doi; 10.1016/j.seizure.2016.03.006.
  • Ferraris C, Guglielmetti M, Pasca L, De Giorgis V, Ferraro OE, Brambilla I, et al. Impact of the ketogenic diet on linear growth in children: A single-center retrospective analysis of 34 cases. Nutrients. 2019; 11(7), 1442. doi; 10.3390/nu11071442.
  • Aydoğdu GS, Akbulut G. Aralıklı açlık diyetleri ve düşük karbonhidratlı diyetlerin obezite tedavisindeki etkinliği. Bes Diy Derg. 2020; 48(1), 98-106. doi; 10.33076/2020.BDD.1302.
  • Food Insight. 2021 Food and Health Survey. 2021. Available from: https://foodinsight.org/2021-food-health-survey/ [Erişim Tarihi: 19.01.2022].
  • Brouns F. Overweight and diabetes prevention: ıs a low-carbohydrate- high diet recommendable? European Journal of Nutrition. 2018; 57(4), 1301-1312. doi; 10.1007/s00394-018-1636-y.
  • Heikura IA, Burke LM, Hawley JA, Ross ML, Garvican-Lewis L, Sharma AP, et al. A short-term ketogenic diet ımparis markers of bone health in response to exercise. Frontiers in Endocrinology. 2019; 10, 880. doi; 10.3389/fendo.2019.00880.

Effectiveness of Ketojenik Diets in Obesity Treatment

Year 2023, Volume: 10 Issue: 1, 45 - 55, 23.06.2023

Abstract

According to the World Health Organization (WHO), the worldwide prevalence of obesity has tripled since 1975 and has reached epidemic proportions. Prevention and treatment of obesity is based on lifestyle changes that include eating habits, physical activity, and behavioral therapy. Various dietary patterns have been used as nutritional strategies, and in recent years there has been interest in ketogenic diets as an adjunctive treatment for epilepsy. Ketone bodies are used instead of glucose, which is the main energy source of the brain, by keeping the carbohydrate rate low in ketogenic diets, and it affects appetite hormones, microbiota, and body weight loss through various mechanisms. The aim of this review is to examine the current literature information on body weight loss and management by examining various mechanisms on appetite hormones and microbiota of ketogenic diets.

References

  • Küçük CK, Yıbar A. Popüler diyet akımlarının vücut ağırlığı ve sağlık üzerine etkileri. Akademik Gıda. 2021; 19(1): 98-107. doi: 10.24323/akademik-gida.927722.
  • World Health Organization. Obesity and Overweight. 2021. Available from: https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight [Erişim Tarihi: 12.10.2021].
  • Rosa DC, Lattanzi G, Taylor SF, Manfrini S, Khazrai YM. Very low calorie ketogenic diets in overweight and obesity treatment: effect on anthropometric parameters, body composition, satiety, lipid profile and microbiota. Obesity Research and Clinical Practice. 2020; 14(6), 491-503. doi: 10.1016/j.orcp.2020.08.009.
  • Deemer SE, Plaisance EP. Impact of Ketosis on appetite regulation – A review. Nutr Res. 2020; 77, 1-11. doi: 10.1016/j.nutres.2020.02.010.
  • Türkiye İstatistik Kurumu. Türkiye Sağlık Araştırması, 2019. 2020. Erişim Linki: https://data.tuik.gov.tr/Bulten/Index?p=Turkey-Health-Survey-2019-33661 [Erişim Tarihi: 12.12.2021].
  • Benelam B. Satiation, satiety and their effect on eating behaviour. Nutrition Bulletin. 2009; 34(2), 126-173. doi: 10.1111/j.1467-3010.2009.01753.x.
  • Gibson AA, Sainsbury A. Strategies to improve adherence to dietary weight loss interventions in research and real-world settings. Behav Sci. 2017; 7(3), 44. doi: 10.3390/bs7030044.
  • Koliaki C, Spinos T, Spinou M, Brinia, ME, Mitsopoulou D, Katsilambros N. Defining the optimal dietary approach for safe, effective and sustainable weight loss in overweight and obese adults. Healthcare. 2018; 6(3),73. doi; 10.3390/healthcare6030073.
  • Metin S. Epilepsi ve ketojenik diyetler. Tayfur M, editör. Beslenme ve Diyetetik Güncel Konular-4. 2.baskı. Ankara: Hatipoğlu Yayıncılık; 2021. S. 81-95.
  • Liu H, Yang Y, Wang Y, Tang H, Zhang F, Zhang Y, et al. Ketogenic diet for treatment of intractable epilepsy in adults: A meta-analysis of observational studies. Epilepsia. 2018; 3(1), 9–17. doi; 10.1002/epi4.12098.
  • Paoli A, Rubini AL, Volek JS, Grimaldi KA. Beyond weight loss: A review of the therapeutic uses of very-low carbohydrate (ketogenic) diets. Eur J Clin Nutr. 2013; 67(8), 789–96. doi; 10.1038/ejcn.2013.116.
  • Goday A, Bellido D, Sajoux I, Crujeiras AB, Burguera B, Garcìa Luna PP, et al. Short-term safety, tolerability and efficacy of a very low calorie ketogenic diet ınterventional weight loss program versus hypocaloric diet in patients with type 2 diabetes mellitus. Nutr Diabetes. 2016; 6(9), e230. doi; 10.1038/nutd.2016.36.
  • Calcaterra V, Verduci E, Pascuzzi MC, Magenes VC, Fiore G, Di Profio E, et al. Metabolic derangement in pediatric patient with obesity: The role of ketogenic diet as therapeutic tool. Nutrients. 2021; 13(8), 2805. doi; 10.3390/nu13082805.
  • van der Louw E, van den Hurk D, Neal E, Leiendecker B, Fitzsimmon G, Dority L, Thompson L, Marchió M, Dudzi´nska M, Dressler A, et al. Ketogenic diet guidelines for infants with refractory epilepsy. Eur J Paediatr Neurol 2016; 20(6), 798–809. doi; 10.1016/j.ejpn.2016.07.009.
  • Goswami JN, Sharma S. Current perspectives on the role of the ketogenic diet in epilepsy management. Neuropsychiatr Dis Treat. 2019; 15, 3273–3285. doi; 10.2147/NDT.S201862.
  • Drabinska N, Wiczkowski W, Piskula MK. Recent advances in the application of a ketogenic diet for obesity management. Trends in Food Science and Technology. 2021; 110, 28-38. doi; 10.1016/j.tifs.2021.01.080.
  • Ünalp A. Çocukluk çağı epilepsilerinde ketojenik diyet uygulamaları. İzmir Dr. Behçet Uz Çocuk Hast. Dergisi. 2017; 7(3), 169-177. doi; 10.5222/buchd.2017.169.
  • Kossoff EH, Zuhec-Kania BA, Amark PE, Ballaban-Gil KR, Christina Bergqvist AG, Blackford R, et al. Optimal clinical management of children reveiving the ketogenic diet: recommendations of the ınternational ketogenic diet study group. Epilepsia. 2009; 50, 304-317. doi; 10.1111/j.1528-1167.2008.01765.x.
  • Neal EG, Chaffe H, Schwartz RH, Lawson MS, Edwards N, Fitzsimmons G, et al. The ketogenic diet for the treatment of childhood epilepsy: Randomised controlled trial. Lancet Neurol. 2008; 7(6), 500-6. doi; 10.1016/S1474-4422(08)70092-9.
  • Furukawa K, Shigematus K, Iwase Y, Mikami W, Hoshi H, Nishiyama T, et al. Clinical effects of one year of chemotherapy with a modified medium-chain triglyceride ketogenic diet on the recurrence of stage ıv colon cancer. Journal of Japanese Society for Parenteral and Enteral Nutrition. 2018; 33(5), 1139-1146. doi; 10.11244/jspen.33.1139.
  • Veyrat-Durebex C, Reynier P, Procaccio V, Hergesheimer R, Corcia P, Andres CR, Blasco H. How can a ketogenic diet improve motor function? Front Mol Neurosi. 2018; 26;11, 15. doi; 10.3389/fnmol.2018.00015.
  • Paoli A. Ketogenic diet for obesity: friend or foe? Int J Environ Res Public Health. 2014; 11(2), 2092–107. doi; 10.3390/ijerph110202092.
  • Kumar S, Behl T, Sachdeva M, Sehgal A, Kumari S, Kumar A, Kaur G, Yadav HN, Bungau S. Implicating the effect of ketogenic diet as a preventive measure to obesity and diabetes mellitus. Life Sci. 2021; 264(1), 118661. doi; 10.1016/j.lfs.2020.118661.
  • O’Neill B, Raggi P. The ketogenic diet: Pros and cons. Atherosclerosis. 2020; 292, 119-126. doi; 10.1016/j.atherosclerosis.2019.11.021.
  • Gibson AA, Seimon RV, Lee CMY, Ayre J, Franklin J, Markovic TP, et al. Do ketogenic diets really suppress appetite? A systematic review and meta-analysis. Obes Rev. 2015; 16(1), 64–76. doi; 10.1111/obr.12230.
  • Coutinho SR, With E, Rehfeld JF, Kulseng B, Truby H, Martins C. The ımpact of rate of weight loss on body composition and compensatory mechanisms during weight reduction: A randomized control trial. Clin Nutr. 2018; 37(4), 1154–62. doi; 10.1016/j.clnu.2017.04.008.
  • Nymo S, Coutinho SR, Torgersen LH, Bomo OJ, Haugvaldstad I, Truby H, et al. Timeline of changes in adaptive physiological responses, at the level of energy expenditure, with progressive weight loss. Br J Nutr. 2018; 120(2), 141–9. doi; 10.1017/S0007114518000922.
  • Sumithran P, Prendergast LA, Delbridge E, Purcell K, Shulkes A, Kriketos A, et al. Ketosis and appetite-mediating nutrients and hormones after weight loss. Eur J Clin Nutr. 2013; 67(7), 759–64. doi; 10.1038/ejcn.2013.90.
  • Paoli A, Bosco G, Camporesi EM, Mangar D. Ketosis, ketogenic diet and food intake control: A complex relationship. Front Psychol. 2015;2; 6:27. doi; 10.3389/fpsyg.2015.00027.
  • Meidenbauer JJ, Ta N, Seyfried TN. Influence of a ketogenic diet, fish-oil and calorie restriction on plasma metabolites and lipids in C57BL/6J mice. Nutr Metab. 2014; 22;11, 23. doi; 10.1186/1743-7075-11-23.
  • De Luis, D., Domingo, J.C., Izaola, O., Cazanueva, F.F., Bellido, D., Sajaoux, I. 2016) Effect of DHA Supplementation in A Very Low-Calorie Ketogenic Diet in The Treatment of Obesity: A Randomized Clinical Trial. Endocrine, 54(1), 111-122.
  • Benani A, Troy S, Carmona MC, Fioramonti X, Lorsignol A, Leloup C, et al. Role for mitochondrial reactive oxygen species in brain lipid sensing: Redox regulation of food intake. Diabetes. 2007; 56(1), 152–160. doi; 10.1007/s12020-016-0964-z.
  • Caprio M, Infante M, Moriconi E, Armani A, Fabbri A, Mantovani G, et al. Very-low-calorie ketogenic diet (vlckd) in the management of metabolic diseases: Systematic review and consensus statement from the ıtalian society of endocrinology (SIE). J Endocrinol Invest. 2019; 42(11), 1365–86. doi; 10.1007/s40618-019-01061-2.
  • Falsaperla R, D’Angelo G, Pratico AD, Mauceri L, Barbagallo M, Pavone P, et al. Ketogenic diet for ınfants with epilepsy: A literature review. Epilepsy Behav. 2020; 112,107361. doi; 10.1016/j.yebeh.2020.107361.
  • Ni FF, Li CR, Liao JX, Wang GB, Lin SF, Xia Y, et al. The effects of ketogenic diet on the Th17/Treg cells ımbalance in patients with ıntractable childhood epilepsy. Seizure. 2016; 38, 17–22. doi; 10.1016/j.seizure.2016.03.006.
  • Ferraris C, Guglielmetti M, Pasca L, De Giorgis V, Ferraro OE, Brambilla I, et al. Impact of the ketogenic diet on linear growth in children: A single-center retrospective analysis of 34 cases. Nutrients. 2019; 11(7), 1442. doi; 10.3390/nu11071442.
  • Aydoğdu GS, Akbulut G. Aralıklı açlık diyetleri ve düşük karbonhidratlı diyetlerin obezite tedavisindeki etkinliği. Bes Diy Derg. 2020; 48(1), 98-106. doi; 10.33076/2020.BDD.1302.
  • Food Insight. 2021 Food and Health Survey. 2021. Available from: https://foodinsight.org/2021-food-health-survey/ [Erişim Tarihi: 19.01.2022].
  • Brouns F. Overweight and diabetes prevention: ıs a low-carbohydrate- high diet recommendable? European Journal of Nutrition. 2018; 57(4), 1301-1312. doi; 10.1007/s00394-018-1636-y.
  • Heikura IA, Burke LM, Hawley JA, Ross ML, Garvican-Lewis L, Sharma AP, et al. A short-term ketogenic diet ımparis markers of bone health in response to exercise. Frontiers in Endocrinology. 2019; 10, 880. doi; 10.3389/fendo.2019.00880.
There are 40 citations in total.

Details

Primary Language Turkish
Subjects Health Care Administration
Journal Section Derleme Bölümü
Authors

Nida Nur Adiyan 0000-0003-0219-2061

Zeynep Parlak Özer 0000-0002-1571-8950

Publication Date June 23, 2023
Submission Date September 14, 2022
Published in Issue Year 2023 Volume: 10 Issue: 1

Cite

APA Adiyan, N. N., & Parlak Özer, Z. (2023). Ketojenik Diyetlerin Obezite Tedavisindeki Etkinliği. ERÜ Sağlık Bilimleri Fakültesi Dergisi, 10(1), 45-55.