Popular Diets: A Scientific Review: Obesity Research March 2001

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Popular Diets: A Scientiﬁc Review
Article in Obesity Research · March 2001
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Popular Diets: A Scientific Review
Marjorie R. Freedman, Janet King, and Eileen Kennedy
EXECUTIVE SUMMARY
Introduction selection of goal weights were appearance and physical

Weight loss is a major concern for the US population. comfort rather than change in medical condition or weight
Surveys consistently show that most adults are trying to lose suggested by a doctor or health care professional. Is it any
or maintain weight (1). Nevertheless, the prevalence of wonder that overweight individuals are willing to try any
overweight and obesity has increased steadily over the past new diet that promises quick, dramatic results more in line
30 years. Currently, 50% of all adult Americans are con- with their desired goals and expectations than with what
sidered overweight or obese (2,3). These numbers have good science supports?
serious public health implications. Excess weight is associ- The proliferation of diet books is nothing short of phe-
ated with increased mortality (4) and morbidity (5). It is nomenal. A search of books on Amazon.com using the key
associated with cardiovascular disease, type 2 diabetes, words “weight loss” revealed 1214 matches. Of the top 50
hypertension, stroke, gallbladder disease, osteoarthritis, best-selling diet books, 58% were published in 1999 or 2000
sleep apnea and respiratory problems, and some types of and 88% were published since 1997. Many of the top 20
cancer (6,7). best sellers at Amazon.com promote some form of carbo-
Most people who are trying to lose weight are not using hydrate (CHO) restriction (e.g., Dr. Atkins’ New Diet Rev-
the recommended combination of reducing caloric intake olution, The Carbohydrate Addict’s Diet, Protein Power,
and increasing physical activity (1). Although over 70% of Lauri’s Low-Carb Cookbook). This dietary advice is
persons reported using each of the following strategies at counter to that promulgated by governmental agencies (US
least once in 4 years, increased exercise (82.2%), decreased Department of Agriculture [USDA]/Department of Health
fat intake (78.7%), reduced food amount (78.2%,) and re- and Human Services, National Institutes of Health) and
duced calories (73.2%), the duration of any one of these nongovernmental organizations (American Dietetic Associ-
behaviors was brief. Even the most common behaviors were ation, American Heart Association, American Diabetes
used only 20% of the time (8). Association, American Cancer Society, and Shape Up
Obesity-related conditions are significantly improved America!).
with modest weight loss of 5% to 10%, even when many What is really known about popular diets? Is the in-
patients remain considerably overweight (6). The Institute formation scientifically sound? Are popular diets effec-
of Medicine (9) defined successful long-term weight loss as tive for weight loss and/or weight maintenance? What is
a 5% reduction in initial body weight (IBW) that is main- the effect, if any, on composition of weight loss (fat vs.
tained for at least 1 year. Yet data suggest that such losses lean body mass), micronutrient (vitamin and mineral)
are not consistent with patients’ goals and expectations. status, metabolic parameters (e.g., blood glucose, insulin
Foster (10) reported that in obese women (mean body mass sensitivity, blood pressure, lipid levels, uric acid, and
index [BMI] of 36.3 ⫾ 4.3) goal weights targeted, on ketone bodies)? Do they affect hunger and appetite, psy-
average, a 32% reduction in IBW, implying expectations chological well-being, and reduction of risk for chronic
that are unrealistic for even the best available treatments. disease (e.g., coronary heart disease, diabetes, and osteo-
porosis)? What are the effects of these diets on insulin
Interestingly, the most important factors that influenced the
and leptin, long-term hormonal regulators of energy in-
take and expenditure?
Address correspondence to Dr. Janet King, U.S. Department of Agriculture, Agricultural The objective of this article is to review the scientific
Research Service, Western Human Nutrition Research Center, University of California, 1 literature on various types of popular diets based on their
Shield Avenue, Building Surge IV, Room 213, Davis, CA 95616. E-mail: jking@
whnrc.usda.gov
macronutrient composition in an attempt to answer these
Copyright © 2001 NAASO questions (see Appendix for diet summaries).
OBESITY RESEARCH Vol. 9 Suppl. 1 March 2001 1S

Popular Diets: A Scientific Review, Freedman, King, and Kennedy
Evidence-Based Guidelines ⬃1400 to 1500 kcal/d, regardless of macronutrient com-

This article is limited to the effects of popular diets in position, results in weight loss. Individuals consuming
overweight and obese adults; there are no good data on high-fat, low-CHO diets may lose weight because the
children and adolescents. Dietary claims are scrutinized, intake of protein and fat is self-limiting and overall
diets are analyzed, and information is compared with sci- caloric intake is decreased (11,12). Low-fat and VLF
entific data published in peer-reviewed journals. No pub- diets contain a high proportion of complex CHOs, fruits,
lished studies are excluded, despite inherent methodological and vegetables. They are naturally high in fiber and low
problems (e.g., small or inadequate sample size, limited in caloric density. Individuals consuming these types of
duration, lack of adequate controls and randomization, poor diets consume fewer calories and lose weight (13–17).
or minimal dietary collection and/or description of diets, Balanced nutrient reduction diets contain moderate
and potential biases). However, the strength of the evidence amounts of fat, CHO, and protein. When overall caloric
supporting various conclusions made throughout the paper intake is reduced, these diets result in loss of body weight
is based on the following grading system used by National and body fat (6,18). Importantly, moderate-fat, balanced
Heart, Lung, and Blood Institute (NHLBI) (6) (Table 1). nutrient reduction diets produce weight loss even when
they are consumed ad libitum.
Characterization of Diets In sum, all popular diets, as well as diets recommended
Diets are characterized below and in Tables 2 and 3. by governmental and nongovernmental organizations, result
● High-fat (55% to 65%), low-CHO (⬍100 g of CHO per in weight loss. However, it is important to note that weight
day), high-protein diets (e.g., Dr. Atkins’ New Diet Rev- loss is not the same as weight maintenance.
olution, Protein Power, Life Without Bread).
● Moderate-fat (20% to 30%), balanced nutrient reduction
diets, high in CHO and moderate in protein (e.g., USDA Evidence Statement: Caloric balance is the major
Food Guide Pyramid, DASH diet, Weight Watchers). determinant of weight loss. Diets that reduce caloric
● Low-fat (11% to 19%), and very-low-fat (VLF) (⬍10%), intake result in weight loss. In the absence of physical
very-high-CHO, moderate-protein diets (e.g., Dr. Dean activity, the optimal diet for weight loss contains
Ornish’s Program for Reversing Heart Disease, Eat ⬃1400 to 1500 kcal/d, regardless of macronutrient
More, Weigh Less, The New Pritikin Program). composition. Evidence Category A.
Evidence Statement: Free-living overweight indi-
Summary of Findings viduals who self-select high-fat, low-CHO diets con-
Weight Loss sume fewer calories and lose weight. Evidence Cat-
Diets that reduce caloric intake result in weight loss. In egory C.
the absence of physical activity, a diet that contains
Table 1. Grading system and evidence categories

Evidence category Sources of evidence Definition
A RCTs (rich body of data) Evidence is from endpoints of well-designed RCTs (or
trials that depart only minimally from
randomization) that provide a consistent pattern of
findings in the population for which the
recommendation is made.
B RCTs (limited body of data) Evidence is from endpoints of intervention studies that
include only a limited number of RCTs, post hoc or
subgroup analysis of RCTs, or meta-analysis of
RCTs. In general, Category B pertains when few
randomized trials exist, they are small in size, and
the trial results are somewhat inconsistent.
C Nonrandomized trials observational studies Evidence is from outcomes of uncontrolled or
nonrandomized trials or from observational studies.
RCT, randomized controlled trial.
2S OBESITY RESEARCH Vol. 9 Suppl. 1 March 2001

than body fat (23). When these diets end, water weight is
Table 2. Characterization of diets as percentage of regained (24). Eventually, however, all reduced calorie diets
calories result in loss of body fat if sustained long term (25).
Fat CHO Protein Physical activity, an important factor with respect to lean
body mass, should be promoted to enhance the effects of
Type of diet (% kcals) (% kcals) (% kcals)
diet on body composition.
High-fat, low-CHO 55–65 ⬍20% (⬍100 g) 25–30
Moderate-fat, 20–30 55–60 15–20
balanced nutrient Evidence Statement: All low-calorie diets result
reduction in loss of body weight and body fat. Macronutrient
Low- and very- ⬍10–19 ⬎65 10–20 composition does not seem to play a major role.
low-fat Evidence Category A
Evidence Statement: In the short term, low-CHO
ketogenic diets cause a greater loss of body water
than body fat. Water weight is regained when the diet
Evidence Statement: Overweight individuals con- ends. If the diet is maintained long term, it results in
suming high-fat, low-CHO, low-calorie diets under loss of body fat. Evidence Category C.
experimental conditions lose weight. Evidence Cate-
gory C.
Evidence Statement: Overweight individuals con- Nutritional Adequacy
suming moderate-fat, balanced nutrient reduction di- Proper food choices are always important when consid-
ets lose weight because they consume fewer calories. ering the nutritional quality of a diet. When individuals
These diets can produce weight loss when consumed consume foods from all food groups, it is more likely that
ad libitum. Evidence Category A. their diet will be nutritionally adequate. The moderate-fat,
Evidence Statement: Overweight individuals con- balanced nutrient reduction diet is optimal for ensuring
suming low-fat and VLF diets lose weight because adequate nutritional intake. However, poor food choices
they consume fewer calories. Evidence Category B. may result in inadequate levels of nutrients (e.g., calcium,
Evidence Statement: Weight loss on VLF diets iron, zinc), regardless of overall macronutrient composition.
may be the result of lifestyle modification, which may High-fat, low-CHO diets are nutritionally inadequate. They
include decreased fat and energy intake, increased are low in vitamins E, A, thiamin, B6, folate, calcium,
energy expenditure, or both. Evidence Category B. magnesium, iron, potassium, and dietary fiber, and require
supplementation. These diets are high in saturated fat and
cholesterol. VLF diets are low in vitamins E, B12, and zinc
Body Composition because meat and fat intake is low.
As body weight decreases, so does body fat and lean body
mass. The optimal diet for weight loss is one that maximizes
loss of body fat and minimizes loss of lean body mass. All
low-calorie diets result in loss of body weight and body fat Evidence Statement: With proper food choices,
(6). Macronutrient composition does not seem to play a the moderate-fat, balanced nutrient reduction diet is
major role (19 –22). In the short-term, however, high-fat, nutritionally adequate. Evidence Category B.
low-CHO ketogenic diets cause a greater loss of body water
Table 3. Characterization of diets in absolute amount (grams)

Type of diet Total kcals Fat g (%) CHO g (%) Protein g (%)
Typical American 2200 85 (35) 275 (50) 82.5 (15)
High-fat, low-CHO 1414* 94 (60) 35 (10) 105 (30)
Moderate-fat, balanced nutrient reduction 1450 40 (25) 218 (60) 54 (15)
Low- and very-low-fat 1450 16–24 (10–15) 235–271 (65–75) 54–72 (15–20)
* Based on average intake of subjects who self-selected low-CHO diets (see Table 4).

Evidence Statement: High-fat, low-CHO diets are Evidence Statement: Low-fat and very low-fat
nutritionally inadequate, and require supplementa- diets reduce LDL-cholesterol, and may also decrease
tion. Evidence Category C. plasma TG levels, depending on diet composition. Ev-
Evidence Statement: VLF diets are low in vita- idence Category B.
mins E, B12, and zinc. Evidence Category B. Evidence Statement: Moderate-fat, balanced nu-
trient reduction diets reduce LDL-cholesterol, nor-
malize the ratio of HDL/TC, and normalize plasma
TGs. Evidence Category A.
Metabolic Parameters
Low-CHO diets result in ketosis, and may cause a sig-
nificant increase in blood uric acid concentrations.
Hunger and Compliance
Blood lipid levels (e.g., total cholesterol [TC], low-den- Many factors influence hunger, appetite, and subsequent
sity lipoprotein [LDL], high-density lipoprotein [HDL] and food intake. Macronutrient content of the diet is one, and it
triglycerides [TGs]) decrease as body weight decreases may not be the most important. Neurochemical factors (e.g.,
(6,26,27). However, the macronutrient and fatty acid com- serotonin, endorphins, dopamine, hypothalamic neuropep-
position of energy-restricted diets can exert substantial ef- tide transmitters), gastric signals (e.g., peptides, stomach
fects on blood lipids. There are significantly greater de- distention), hedonistic qualities of food (e.g., taste, texture,
creases in LDL cholesterol during active weight loss when smell), genetic, environmental (e.g., food availability, cost,
diets are low in saturated fatty acids. Changes in HDL cultural norms) and emotional factors (e.g., eating when
cholesterol depend on dietary fat content and duration of bored, depressed, stressed, happy) must be considered.
energy restriction (28). Moderate-fat, balanced nutrient re- These parameters influence appetite primarily on a meal-to-
duction diets reduce LDL-cholesterol and normalize the meal basis. However, long-term body weight regulation
ratio of HDL/TC. seems to be controlled by hormonal signals from the endo-
Plasma TG levels also decrease with weight loss (6). crine pancreas and adipose tissue, i.e., insulin and leptin.
Although they increase in response to short-term consump- Because insulin secretion and leptin production are influ-
tion of a VLF, high-CHO diet (29), the type of CHO enced by the macronutrient content of the diet (36,37),
consumed must be considered. High-fiber foods, including effects of different diets on these long-term regulators of
vegetables and legumes, do not lead to hypertriglyceridemia energy balance also need to be considered when investigat-
(30), and may easily be incorporated into moderate-fat, ing hunger and appetite.
balanced nutrient reduction diets to help normalize plasma All fat-restricted diets provide a high degree of satiety.
TG levels. Subjects who consume fat-restricted diets do not complain of
hunger, but of having “too much food” (38,39). These diets,
Energy restriction, independent of diet composition, im-
high in fiber and water content are low in caloric density.
proves glycemic control (21,22,31–33). As body weight
Subjects who consume these diets develop a distaste for fat
decreases, so does blood insulin and plasma leptin levels
(40), which may be useful in long-term adherence to reduced
(21,34).
fat, low-calorie diets. However, it is not clear that restricting fat
Blood pressure decreases with weight loss, independent provides any advantage over restricting CHOs. Ogden (41)
of diet composition (6,22,26). However, the DASH diet, reports weight loss maintainers used healthy eating habits and
high in fruits, vegetables, and low-fat dairy products effec- adhered to calorie-controlled diets.
tively lowers blood pressure (35). Long-term compliance to any diet means that short-term
weight-loss has a chance to become long-term weight main-
tenance (42– 44). Dietary compliance is likely a function of
psychological issues (e.g., frequency of dietary counseling,
Evidence Statement: High-fat, low-CHO diets re- coping with emotional eating, group support) rather than
sult in ketosis. Evidence Category B. macronutrient composition, per se (42,45). Being conscious
Evidence Statement: Metabolic profiles are im- of one’s behaviors, using social support, confronting prob-
proved with energy restriction and weight loss. Evi- lems directly, and using personally developed strategies
dence Category A. may enhance long-term success (46). Ogden (41) notes that
Evidence Statement: Low-CHO diets that result successful weight loss and maintenance may be predicted
in weight loss may also result in decreased blood lipid by an individuals’ belief system (e.g., that obesity is per-
levels, decreased blood glucose and insulin levels, ceived as a problem that can be modified and if modifica-
and decreased blood pressure. Evidence Category C. tions bring changes in the short-term that are valued by the
individual concerned).

weight loss. They claim that “most overweight individuals

Evidence Statement: Many factors influence hun- do not overeat” (48, p. 7; 50, p. 21), even as they suggest
ger, appetite, and subsequent food intake. There does that high-CHO meals leave individuals less satisfied than
not seem to be an optimal diet for reducing hunger. meals that contain adequate fat, resulting in increased hun-
Evidence Category B. ger and increased food intake (48, p. 55; 50, p. 43). They
Evidence Statement: Long-term compliance is suggest that those who do overeat do so “because of a
likely a function of psychological issues rather than metabolic component driving them on, most often a truly
macronutrient composition. Evidence Category B. addictive craving for CHOs” (48, p. 7; 52, p. 142). Because
“carbohydrates are addictive,” the carbohydrate “addict”
continues to eat carbohydrates, producing more and more
Summary and Recommendations
insulin, which inhibits brain serotonin release. Reductions
Caloric balance (calories in vs. calories out), rather than
in this “satiety” neurotransmitter result in a decreased sense
macronutrient composition is the major determinant of
of satisfaction (50, pp. 26, 43; 51, p. 41). With respect to
weight loss. However, what is not clear is the effect of
weight loss, Atkins (48) claims that on a low-CHO diet
macronutrient content on long-term weight maintenance
and adherence. Furthermore, it is not known whether main- there are “metabolic advantages that will allow overweight
tenance of weight loss and dietary adherence is related to individuals to eat as many or more calories as they were
psychological issues (and brain neurochemistry), physiolog- eating before starting the diet yet still lose pounds and
ical parameters (e.g., hormones involved in body weight inches” (p. 10).
regulation such as insulin and leptin), physical activity, Furthermore, proponents contend overproduction of in-
energy density, or some other factor(s). sulin, driven by high CHO intake, is the cause of the
Controlled clinical trials of high-fat, low-CHO, and low- metabolic imbalance that underlies obesity (48,50,53). Eat-
fat and VLF diets are needed to answer questions regarding ing too much CHO results in increased blood glucose,
long-term effectiveness (e.g., weight maintenance rather increased blood insulin, and increased TGs (48, pp. 50 –51).
than weight loss) and potential long-term health benefits An already overweight person who continues to overeat
and/or detriments. CHOs develops hyperinsulinemia and insulin resistance,
Prevention of weight gain and weight maintenance are “resulting in insulin’s lack of effectiveness in converting
important goals. Scientifically validated, yet understandable glucose into energy, but enabling glucose (e.g., dietary
information is clearly needed by millions of overweight and CHO) to be stored as fat” (48, p. 52).
obese Americans who often find weight loss attainable, but Advocates of low-CHO diets propose a simple solution to
maintaining weight loss nearly impossible. this “vicious cycle” of CHO addiction, CHO overeating,
hyperinsulinemia, decreased glucose use and increased fat
storage. It involves restricting CHOs severely enough to
I. High-Fat, Low-Carbohydrate Diets produce ketosis. The ketosis is a reliable indicator of fat
(55% to 65% fat, <100 g of CHO per day) mobilization. In this condition, the key benefit is that blood
Despite controversy surrounding their use, high-fat, low-
glucose and blood insulin levels are reduced, and appetite is
CHO diets are among the most popular types of diets today.
suppressed. In short, authors contend that a high-fat, low-
The most famous is Dr. Atkins’ Diet Revolution (47) first
CHO, high-protein, ketogenic diet results in weight loss,
published in 1972, and updated 20 years later as Dr. Atkins’
New Diet Revolution (48). Promoting a “lifetime nutritional body fat loss, preservation of lean body mass, and correc-
philosophy,” Atkins claims that his diet has been embraced tion of serious medical complications of diabetes (51), heart
by an estimated 20-plus million people worldwide since the disease, and high blood pressure (48, pp. 6, 63). The con-
release of his first book (www.atkinscenter.com). His pro- tention is that the high-fat, low-CHO diet supports long-
gram was one of the first to popularize low-CHO, high- term health, controls weight without hunger, and should be
protein, ketogenic diets that individuals could use on their followed for the rest of one’s life (48, p. 27).
own, rather than in a medical setting (e.g., a protein-sparing
modified fast). Other low-CHO diets with similar themes B. Scientific Evaluation of Claims
include Protein Power (49), The Carbohydrate Addict’s 1. Caloric Intake, Body Weight, and Body Composition
Diet (50), Dr. Bernstein’s Diabetes Solution (51), and Life
Without Bread (52). ● Is caloric intake relevant when looking at weight gain
and weight loss?
A. Underlying Philosophy, Claims, and Proposed ● What is the effect of diet composition on weight loss,
Solutions e.g., will consuming a high-fat, low-CHO diet, regard-
Proponents of high-fat, low-CHO diets dismiss the notion less of caloric intake, result in weight loss, body fat
that caloric intake is important to either weight gain or loss, and preservation of lean body mass?

ance, weight loss is a function of caloric intake, not diet

Table 4. Diet composition of subjects who self- composition (54). Table 4 indicates diet composition of
selected low-CHO diets individuals who self-select high-fat, low-CHO diets, and
CHO Fat Protein Tables 5a and 5b show weight change in obese individuals
Total consuming high-fat, low-CHO diets. In all cases, individu-
Study kcals g % g % g % als on high-fat, low-CHO diets lose weight because they
consume fewer calories.
Evans (11) 1490 86 24 94 56 75 20
Yudkin (12) 1383 43 12 96 62 80 23
Rickman (56) 1325 7 1 73 50 160 48 Evidence Statement: Free-living overweight indi-
Larosa (57) 1461 6 1.6 108 66 107 29 viduals who self-select high-fat, low-CHO diets con-
sume fewer calories and lose weight. Evidence Cat-
egory C.
Evidence Statement: Overweight individuals consum-
Energy intake and energy expenditure are relevant when
ing high-fat, low-CHO, low-calorie diets under experi-
looking at weight gain and weight loss. Overweight and
mental conditions lose weight. Evidence Category C.
obesity results from an energy imbalance (e.g., excess ca-
loric intake, decreased energy expenditure, or both) (54).
Reduction of body weight and body fat can be achieved by Caloric Intake and Weight Change
creating an energy deficit (e.g., restricting energy intake, Studies cited by Atkins (pp. 67–74) to support his
increasing energy expenditure, or a combination of the two) contentions were of limited duration, conducted on a
(6,18,54). Atkins (48) calls these basic thermodynamic prin- small number of people, lacked adequate controls, and used ill-
ciples “a millstone around the neck of dieters and a miser- defined diets (24,58,61,63– 65,67,68,71). Some of these, as
able and malign influence on their efforts to lose” (p. 6). Do well as other studies, actually refute the contention that low-
followers of high-fat, low-CHO diets have a metabolic CHO diets, in the absence of energy restriction, provide a
advantage that enables them to eat a greater number of metabolic advantage (11,12,21,22,45,56,57,59,60 – 64,66 – 68,
calories, and still lose body weight and body fat? 70,72). These studies are reviewed below.
No scientific evidence exists to suggest that low-CHO
ketogenic diets have a metabolic advantage over more con- Early Studies (Pre-1960)
ventional diets for weight reduction (55). Studies consis- Early studies on a limited number of obese men and
tently show that under conditions of negative energy bal- women indicate individuals consuming low-CHO diets
Table 5a. Effect of low-carbohydrate intake on body weight in obese subjects in studies without a control group(s)
Weight change Weight change
Study n Duration CHO (g) kcal/day (kg) (g/day)
Kekwick (24) 14 5–9 days 10 1000 N/A N/A
Rickman (56) 12 7 days 7 1325 ⫺3.1 ⫺442
Benoit (58) 7 10 days 10 1000 ⫺6.6 ⫺660
Yudkin (12) 6 14 days 43 1383 ⯝2.8 ⫺200
Fletcher (59) 6 14 days 36 800 ⯝3.125 ⫺223
Lewis (60) 10 14 days 27 1115 ⫺5.2 ⫺371
Kasper (61) 16 16 days 56 1707 ⫺4.8 ⫺300
Bortz (62) 9 21 days 0 800 N/A N/A
Krehl (63) 2 30 days 12 1200 N/A N/A
Evans (11) 8 6 wk 80 1490 ⫺3.2 to ⫺5.0 ⫺76 to ⫺119
Golay (22) 22 6 wk 37.5 1000 ⫺8.0 ⫺111
Young (64) 3 6 wk 30 1800 ⫺16.18 ⫺385
Larosa (57) 24 12 wk 6 1461 ⫺6.8 ⫾ 0.91 ⫺81
Golay (21) 31 12 wk 75 1200 ⫺10.2 ⫾ 0.7 ⫺121
Cedarquist (65) 7 16 wk 85 1500 ⫺8.8 to ⫺16.8 ⫺78 to ⫺150

Table 5b. Effect of low-CHO intake on body weight in obese subjects in studies with a control group(s)
CHO Weight change Weight change
Study n Duration (g) kcal/day (kg) (g/day)
Worthington (66) 20 21 days 17 1182 ⫺12.0 ⫾ 3.7 ⫺571
Rabast (67) 13 25 days 48 1871 ⫺8.76 ⫾ 0.74 ⫺350
Rabast (68) 25 30 days 25 1000 ⫺11.77 ⫾ 0.77 ⫺392
Wing (69) 11 4 wk 10 800 ⫺8.1 ⫺270
Alford (45) 11 10 wk 75 1200 ⫺6.4 ⫾ 7.59 ⫺91
Baron (70) 66 3 months 50 1000 ⫺5.0 ⫺55
reduce overall caloric intake and lose weight Studies by Kekwick and Pawan (24,71) are cited by
(12,65,72,73). Pennington’s (73) was one of the earliest Atkins to support his contention that diet composition,
low-CHO diets, and contained less than 60 g CHO per rather than caloric intake, is the key variable for weight loss.
day, an amount “calculated to not interfere with ketogen- Yet, despite this contention, these studies support the notion
esis.” The diet allows 24 ounces of meat with fat daily, that calories do count. Obese individuals confined to a
and one ordinary portion of any of the following: white metabolic ward were given diets with the same ratio of fat,
potatoes, sweet potatoes, boiled rice, half of a grapefruit, protein and CHO, but different caloric values. Individuals
grapes, melon, banana, pear, raspberries, or blueberries; lost more weight when they consumed lower calorie diets
it allows no bread, flour, salt, sugar, or alcohol. The (e.g., 500 and 1000 kcal/d) compared with when they con-
Pennington diet resulted in an unspecified amount of sumed higher calorie diets (e.g., 1500 and 2000 kcal/d). In
weight loss but critics were suspicious that the unpalat- another study, 14 obese patients were fed 1000-kcal diets
ability, or high satiety value of the diet, resulted in food containing either 90% protein (5 g of CHO), 90% fat (10 g
intake well below the minimum recommended 2870 of CHO), or 90% CHO (225 g of CHO). Food available in
kcal/d. However, Pennington concluded, “there is noth- each of the diets was unspecified. Each subject consumed
ing remarkable in the observation that some obese must, the high-fat, high-protein, or high-CHO diet for 5 to 9 days
of necessity, lose weight on an intake of 3000 kcal or before being switched to another diet. Twenty-one days
more per day,” considering their normal intake to be up later, all patients had lost weight, regardless of the order
to 4500 kcal/d (72,73). they had consumed the different diets. However, patients
To substantiate weight loss could occur on 2870 kcal/d, consuming 90% fat lost the most weight over 5 to 9 days,
regardless of diet composition, Werner (72) studied 6 obese whereas those eating 90% CHO lost little or none; some
subjects confined to a metabolic ward for 35 to 49 days. He even gained back some weight lost earlier on the 90% fat or
fed them Pennington’s low-CHO, high-fat diet (2874 kcal, 90% protein diets. These results led Kekwick and Pawan to
52 g CHO, 242 g fat) or an isocaloric, high-CHO, lower-fat suggest, “obese patients must alter their metabolism in
diet (2878 kcal, 287 g CHO, 146 g fat). Apart from transient response to the contents of the diet.” In another study, they
changes in water balance, the rate of weight loss in obese fed five obese individuals 2000 kcal balanced diets for 7
subjects was the same on both diets, showing diet compo- days, followed by a low-CHO, high-fat, high-protein diet
sition did not matter. Atkins (48) called Pennington’s study providing 2600 kcal/d for 4 to 14 days. Although patients
“exciting” (p. 67) yet he dismisses Werner’s study as too could maintain or gain weight on 2000 kcal/d, all, except
high in CHOs to promote ketosis (p. 70), despite the fact one, lost weight on 2600 kcal/d. Weight loss was reported to
that Werner received the diet from Dr. Pennington. be partly from body water (30% to 50%) and partly from
To support the concept of total caloric intake over diet body fat (50% to 70%). Unfortunately, none of these studies
composition, Yudkin and Carey (12), studied six adult over- reported actual food intake, despite the author’s remarks,
weight subjects and found that when they followed a low- “the main hazard was that many of these patients had
CHO diet (⬍30 to 55 g/d) for 2 weeks, caloric intake was inadequate personalities. At worst they would cheat and lie,
reduced 13% to 55% (180 to 1920 fewer daily calories). obtaining food from visitors, from trolleys touring the
Caloric intake averaged 1383 per day. Although all subjects wards, and from neighboring patients.”
were allowed to consume an “unlimited” amount of fat, Convinced that fluid balance, not diet composition, was
none consumed significantly more fat than before, and three the cause of the weight loss reported by Kekwick and
showed a significant reduction of fat intake. Only one Pawan, Pilkington et al. (74) repeated their studies for
showed a slight increase in protein intake. longer periods of time (18 or 24 days). His results were

comparable with Kekwick and Pawan’s during the first few tested positive for urinary ketones on Day 7 and four tested
days on each of the diets. However, there was a steady rate positive on Day 14. The 10 women on the low-CHO diet
of weight loss with each of the 1000-kcal diets thereafter, lost significantly more weight at the end of 14 days com-
regardless of whether the calories came from fat, protein, or pared with the 10 women on the balanced diet (12.0 ⫾ 3.7
CHO. Although he did not measure fluid balance, Pilking- vs. 8.7 ⫾ 3.5, low-CHO vs. balanced). The difference in
ton (74) concluded that temporary differences in weight loss total weight loss was established primarily during the first
were due to such changes. He stated “if the periods of study week, when the average weight loss in the low-CHO group
are long enough to achieve a ‘steady state’ the rate of weight was 8.2 pounds, and that of the control group was 6 pounds.
loss on a diet consisting mainly of fat does not differ During the second week, weight loss was similar for the
significantly from the rate of weight loss on an isocaloric two groups.
diet consisting mainly of CHO.” Oleson and Quaade’s In 1971, Young et al. (64), at Cornell University, looked
(75) experiment, which lasted for 3 weeks, had a similar at the effect of diet composition on weight loss and body
conclusion. composition. Eight moderately obese young male college
students were fed isocaloric diets for 9 weeks (interrupted
Studies from 1961 to 1979 after 3 weeks for 1 week of spring vacation). Each diet
Fletcher et al. (59) gave six obese women who were contained 1800 kcal and 112 g of protein, but different
confined to a metabolic ward 800 kcal/d diets containing amounts of CHO: either 104, 60, or 30 g/d. Physical activity
mostly CHO, protein, or fat. They received each diet for 14 was not controlled. Only those in the 30 g/d group tested
days. The high-fat and high-protein diets each contained positive for ketones throughout the 9-week study. As CHO
36 g of CHO. Statistical analysis showed no significant in the diet decreased, weight and fat loss slightly, but not
difference in the rate of weight loss on the different diets. significantly, increased. Using underwater weighing to de-
Kinsell et al. (19) maintained obese subjects on a fixed termine body composition, Young et al. reported that the
caloric intake and varied the macronutrient composition of weight lost by the lowest CHO group (30 g/d) was close to
the diet (e.g., fat intake varied from 12% to 80%, protein 100% fat. However, no difference between the groups with
from 14% to 26%, and CHO from 3% to 61%). In any given respect to nitrogen, sodium, or potassium balances was
subject, the rate of weight loss after the initial depletion of reported. Young et al. (64) concluded, “it would seem that
fluid was essentially constant throughout the entire study, of the low CHO diets used, the one at the 104-g level would
irrespective of diet composition. Bortz (62) fed an 800-kcal be most suitable for long-term use.” Although their study
liquid formula diet containing 80 g of protein, and either lasted 9 weeks, Atkins extrapolated data to 30 weeks, im-
54 g of fat (no CHO), or 120 g of CHO (no fat) to nine obese plying even greater benefit (p. 73).
subjects who were confined to a metabolic ward. Each diet Rickman (56) monitored weight changes in 12 healthy
was given for 24 days, before switching to the other. No volunteers (hospital employees) who were no more than
difference in rate of weight loss was noted, apart from that 10% above ideal body weight (based on Metropolitan Life
attributable to alterations in sodium and fluid balance. Krehl Insurance tables). Subjects were instructed to follow the
et al. (63) studied four healthy, normal weight male prison Stillman diet, which allowed unlimited quantities of protein
volunteers, and seven obese females (five were from 15 to and fat, but no CHO. Average caloric intake was 1325 per
21 years old, and two were 36 and 53 years old) on a day, with 50% of calories from fat (73 g), 48% from protein
metabolic ward. The obese females were given 1200-kcal, (160 g), and less than 1% from CHO (7 g). Subjects fol-
12-g CHO diets, comprised of fat and protein in different lowed the diet for 3 to 17 days (average 7.6 days). During
ratios (50/50; 60/40; 40/60; 70/30; 30/70). They received the first 3 to 5 days, each subject lost 1.3 to 2.2 kg. At the
each diet for 1 month. They also had three ⬃1-hour periods end, mean weight loss was 3.1 kg. In 8 of 10 subjects for
of supervised physical activity daily. Although it is difficult whom there was follow-up within 7 days of the diet, average
to draw any conclusions from this small study, Krehl et al. weight regain was 2 kg (range, 1 to 4.5 kg).
(63) reported that all patients lost weight at a rate commen- Studies using low-CHO, liquid formula diets conducted
surate with caloric restriction and physical activity, regard- in Germany had small sample sizes, short duration (1
less of diet composition. month), and poor design (61,67,68). Kasper et al. (61)
In another short-term study, Worthington and Taylor (66) compared the weight loss of 16 obese subjects on low-CHO
fed isocaloric diets (1182 kcal/d) for 2 weeks to 20 obese diets (56g/d) with 4 obese subjects on isocaloric (1707
women who were confined to a state correctional institution. kcal), high-CHO diets (156 g/d). The average duration on
One diet was a low-CHO, ketogenic diet (17 g/d) with a the low-CHO diet was 16 days (range, 6 to 30 days); mean
6:48:44 ratio of CHO to protein to fat calories. The other weight loss was 0.3 kg/d. The average duration on the
was a “balanced low-calorie diet” and contained 96 g of high-CHO diet was 10 days (range, 6 to 14 days); mean
CHO and a 32:20:47 ratio of CHO to protein to fat. Al- weight loss was 0.05 kg/d. The small sample size, difference
though this diet was not meant to be ketogenic, two subjects in study duration, and fact that 3 of the 4 subjects on the

high-CHO diet also received the low-CHO diet (before or the low-CHO diet, it averaged 38 ⫾ 19 days (range, 15 to 78
after?) prevents adequate interpretation. Seventeen subjects days). On the high-CHO diet, it averaged 32 ⫾ 13 days
(some of whom had received other diets) were fed a high-fat (range, 18 to 59 days). Due to significant drop out in both
formula diet containing 2150 kcal and 112 g of CHO per groups, data were analyzed only up to Day 30. Results
day. The average length of time on this diet was 18 days indicate by Day 15, the 25 subjects following the low-CHO
(range, 6 to 40 days) and the mean weight loss was 0.32 diet lost significantly more weight than the 20 subjects
kg/d, an amount comparable with the low-CHO, lower following the high-CHO diet (6.81 ⫾ 0.30 kg vs. 5.49 ⫾
calorie (1707) diet. Body composition was not measured 0.37 kg). There was no significant difference in weight loss
during any of these studies. between the groups at Day 20 or 25. By Day 30, the weight
A similar, but better controlled study was conducted by loss between the two groups again reached statistical sig-
Lewis et al. (60). They compared the responses to two nificance (11.77 ⫾ 0.77 kg vs. 9.81 ⫾ 0.43 kg, low-CHO
cholesterol-free, isocaloric (10 kcal/kg per day; ⬃1115 vs. high-CHO, respectively), even though by day 30, almost
kcal), liquid formula diets of differing composition (70% 40% of subjects in each group had dropped out (no reasons
CHO, 20% protein, 10% fat vs. 70% fat, 20% protein, given). Body composition data were not presented, and the
10% CHO) in 10 obese men who were confined to a authors did not report any increased water or electrolyte
metabolic ward. Diets were administered for 14 days in excretions during either of the diets. In another article,
random order and each diet was preceded by a 7-day Rabast et al. (67) presented the exact same data found in the
control, weight-maintenance diet (30 kcal/kg per day, article just described (68). In addition, it included new data
40% CHO, 20% protein, 40% fat). Although the low- from 28 additional subjects who received low-CHO (48
CHO diet was clearly ketogenic, Lewis et al. (60) con- g/d, n ⫽ 13) or high-CHO (355 g/d, n ⫽ 15) liquid
cluded that both low-calorie diets effected similar losses formula diets containing 1900 kcal/d for 25 days. In this
of nonaqueous body weight. Their conclusions regarding study, all subjects lost weight, regardless of caloric intake or
body composition changes were not based on actual body diet composition.
composition measurements. Instead, they were based on The Rabast study that Atkins cites (p. 74) in support of
the significant rebound in body weight and the significant his position actually refutes it. This study confirms
urinary sodium retention observed when the weight weight loss on low-calorie diets, independent of CHO
maintenance diet followed the ketogenic diet, along with content after Day 10 on 1900 kcal, and after Day 15 on
the significant increase in serum albumin concentration 1000 kcal. Atkins cites the difference of 4.2 kg (9.24
noted during the period in which the low-CHO diet was pounds) in total weight loss between the 1000-calorie
ingested. These changes were not seen when the mainte- low-CHO and 1000-calorie high-CHO groups as proof
nance diet followed the high-CHO diet. that the low-CHO diet works better. The problem with
However, to support that low-CHO diets result in loss this is that these data (e.g., the 4.2-kg weight difference)
of body fat, Atkins cites Benoit et al. (58), who compared represent the final weight loss between the two groups at
the effects of 10 days of fasting with a 1000-calorie, 10 g the end of the study (59 to 78 days). However, we have
of CHO ketogenic diet in seven active-duty Naval per- no idea how many subjects actually completed the study.
sonnel (mean weight, 115.6 kg). Over the 10-day period, We do know that of 45 persons who started the study,
the mean weight loss for the fasting and ketogenic groups only 28 remained by Day 30.
were 9.6 kg and 6.6 kg, respectively. The ketogenic diet
resembled fasting in terms of ketosis, acidosis, and mild
anorexia (which the authors speculated may influence Studies after 1980
caloric restriction by the patient). However, the ketogenic Larosa (57) studied 24 obese free-living men and women
diet resulted in greater fat loss (97% vs. 35%) and de- for 12 weeks. For the first 2 weeks, they followed their
creased loss of lean body mass (3% vs. 65%) relative to current diet. For the next 4 weeks, they were instructed to
fasting. Although all patients on both diets were in neg- follow Stage I of the study diet, taken from the book, Dr.
ative N balance, potassium balance seemed unaffected by Atkins’ Diet Revolution (47). Stage I is devoid of CHOs but
the ketogenic diet, an impossibility according to Grande places no caloric limits on protein or fat. Based on urinary
(76), who seriously questioned the scientific validity of ketone measurement all but 3 were confirmed as restricting
Benoit’s entire study. CHOs. After 4 weeks on Stage I, patients advanced to Stage
Atkins cites Rabast et al. (67,68) to support his contention II, which allows 5 to 8 g of CHO per day for an additional
that low-CHO diets result in greater weight loss than high- 4 weeks, bringing the total time on the low-CHO diet to 8
CHO diets. Rabast et al. (66,68) fed 45 obese German men weeks. The final 2 weeks (off the diet) allowed ad libitum
and women 1000-calorie, isonitrogenous, low-CHO (25 intake. No prescription for changes in exercise was given
g/d) or high-CHO (170 g/d) formula diets. The duration of and subjects were asked not to alter their exercise habits
the treatment period differed between the two groups. On from prestudy levels.

Results indicated that all but 2 of 24 subjects lost weight living subjects. Participants included 135 men and women
the first 2 weeks of the study while eating ad libitum. After ranging from barely overweight to frankly obese, recruited
8 weeks on the low-CHO diet, all subjects (except for 1 with the help of six diet clubs in Oxford, England. Within
male) lost weight. Mean weight loss was 4.1 ⫾ 0.64 kg from each participating diet club, subjects were randomly given a
the ad libitum period, and 7.7 ⫾ 0.73 kg from the pre-diet low-CHO diet (⬍50 g/d) or a low-fat/high-fiber diet (⬍30 g
period (10 weeks before). Almost half of the total weight fat/d). All diets contained 1000 kcal/d. Each subject planned
loss occurred in the first 2 weeks on the low-CHO diet. his/her own menus, with the assistance of group leaders and
When subjects resumed ad libitum food intake at the end of study investigators, and received appropriate dietary in-
the 8-week diet period, some weight was gained back struction. Moderate weight loss occurred in both groups
(⫹1.5 ⫾ 0.45 kg). However, data from 21 subjects showed during the 3-month period, although at 1 year, much of this
an overall significant loss of body weight (6.8 ⫾ 0.91 kg) was regained. Body weight changes at 3 months indicated
over the course of the 12-week study. One year later, weight that those following the low-CHO diet, especially women,
data were available from 62% of subjects. Although almost lost more weight than those following the low-fat/high-
all had gained back some of the weight they had previously CHO diet (5.0 vs. 3.7 kg, low-CHO vs. high-CHO). How-
lost while on the low-CHO diet, only 2 subjects weighed ever, further analysis consistently showed club membership
more than they had at the start of the study, whereas 13 (e.g., nature of participants in each club, or effectiveness of
weighed less (mean weight loss 5.9 ⫾ 1.7 kg). Body com- leaders) to be a better predictor of weight loss than compo-
position was not determined. sition of diet.
Results of this uncontrolled study support that low- Golay et al. (21,22) studied the effect of varying levels
CHO diets lead to weight loss. Closer examination re- of CHO intake (15%, 25%, and 45%) on weight loss in
veals weight loss results from caloric restriction. Diet obese subjects. In one study, 68 outpatients followed for
analysis (assessed using food intake records) revealed a 12 weeks received a low-calorie (1200 kcal), 25% CHO
500-kcal decrease in total caloric intake from the start of
(75 g), or 45% CHO diet (21). Protein content of the diets
the study to the end of Stage II, 8 weeks later, when the
was comparable (⬃30%); fat made up the difference.
average intake was 1461 kcal/d. Just as Yudkin and
After 12 weeks, the mean weight loss was similar be-
Carey (12) reported 20 years earlier, when protein and fat
tween the two groups (10.2 ⫾ 0.7 kg vs. 8.6 ⫾ 0.8 kg;
were permitted in unlimited quantities, subjects did not
25% vs. 45% CHO, respectively). Loss of adipose tissue
greatly increase their intake of these nutrients. In fact, fat
was similar. Despite a high protein intake (1.4 g/kg IBW)
intake decreased (5 g) and protein intake only slightly
there was a loss of lean body mass in both groups. The
increased (11 g). The greatest caloric effect was the near
waist-to-hip ratio diminished significantly and identically
total elimination of CHO (165 g).
in both groups. In another study (22), 43 obese inpatients
Alford et al. (45) manipulated CHO content of low-
calorie diets (1200 kcal/d) to determine possible effects followed for 6 weeks received a low-calorie diet (1000
on body weight and body fat reduction over 10 weeks. At kcal), and participated in a structured, multidisciplinary
least 11 women in each diet group consumed either a program that included physical activity (2 h/d), nutri-
low-, medium-, or high-CHO diet. The low-CHO diet tional education, and behavioral modification. The natu-
was 15% to 25% CHO (75 g/d) (30% protein, 45% fat), ral food diet contained either 15% CHO (37.5 g), or 45%
the moderate-CHO diet was 45% CHO (10% protein, CHO. Protein content of the diets was comparable
35% fat), and the high-CHO diet was 75% CHO (15% (⬃30%); fat made up the difference. After 6 weeks, there
protein, 10% fat). The women were free-living, but at- was no significant difference in weight loss in response
tended weekly classes on nutrition and behavior modifi- to either diet (8.9 ⫾ 0.6 kg vs. 7.5 ⫾ 0.5 kg; 15% vs. 45%
cation. All were sedentary and agreed to remain so for the CHO, respectively). Significant and comparable de-
duration of the study. Weight loss occurred in all groups, creases in total body fat and waist-to-hip ratios were seen
but there was no significant difference in weight loss in both groups. Both studies show that energy intake, not
among the groups. Percent body fat loss, based on un- diet composition determines weight loss and fat loss in
derwater weighing was similar among the groups. Alford response to low-energy diets over a short time period.
et al. (45) concluded, “there is no statistically significant Wing et al. (69) confined 21 severely obese women to a
effect derived in an overweight adult female population metabolic ward for 31 days. They were randomly assigned
from manipulation of percentage of CHO in a 1200-kcal to ketogenic (10 g of CHO) or nonketogenic liquid formula
diet. Weight loss is the result of reduction in caloric diets containing ⬃600 kcal/d for 28 days. Weight losses
intake in proportion to caloric requirements.” were comparable between the two diets (mean, 8.1 kg).
Baron et al. (70) conducted a three-month randomized Because the objective was to determine whether ketogenic
controlled trial to determine acceptability of different sets of weight reducing diets have adverse effects on cognitive
dietary advice (e.g., low-CHO vs. low-fat) among free- performance, no data on body composition were obtained.

Table 6. Dr. Atkins’ New Diet Revolution: diet analysis compared with the USDA Food Guide Pyramid
Atkins’ Atkins’ Atkins’ Food guide RDAs, DRVs,
Nutrient induction ongoing maintenance pyramid DRIs*
Total energy (calories) 1152 1627 1990 1972 2000–2200
Moisture (H2O), g 682 736 1132 1879 none
Total fat, g (% total kcal) 75 (59) 105 (58) 114 (52) 54 (24) 65 (30)
Saturated fat, g 29 49 44 17 20
Monounsaturated fat, g 31 36 41 19 20
Polyunsaturated fat, g 6 11 19 15 20
Cholesterol (mg) 753 1115 955 154 300
Total protein, g (% total kcal) 102 (35) 134 (33) 125 (25) 90 (18) 75 (15)
Total CHO, g (% total kcal) 13 (5) 35 (8.6) 95 (19) 292 (59) 55%–60%
Alcohol, g 0 0 14 0 moderation
Dietary fiber (g) 3 8 13 22 20–35
Vitamin E (mg) 3 7 10 40 15
Vitamin A (RE) 669 2183 2231 4140 700
Thiamin (mg) .5 1.4 .7 3.8 1.1
Riboflavin (mg) 1.3 2.5 2.0 4.3 1.1
Niacin (mg) 18 20 25 51 14
Vitamin B6 (mg) 1.2 1.8 2.2 5.5 1.3
Folate (␮g) 135 391 282 1010 400
Vitamin B12 (␮g) 8 8 4.3 17 2.4
Vitamin C (mg) 67 95 226 288 75
Calcium (mg) 294 1701 889 1749 1000
Phosphorus (mg) 1096 1993 1418 1800 700
Magnesium (mg) 126 294 233 425 320
Iron (mg) 10.4 12.6 8.7 39 18
Zinc (mg) 15 14 11.7 31 8
Sodium (mg) 2934 4046 3604 2757 2400
Potassium (mg) 1734 2562 3339 4718 3500
RDAs, Recommended Dietary Allowances; DRVs, Dietary Reference Values; DRIs, Dietary Reference Intakes.
Note: Items in bold indicate values different from RDAs, DRVs, and DRIs.
* RDAs and DRIs used are those of a female, 31–50 years old. Calculated values (DRV) are based on a 2000-kcal diet: 30% total calories
from fat, 10% of total calories from saturated, monounsaturated, and polyunsaturated fat, and 15% total calories from protein.
One might argue that because low-CHO diets result in the early days on a mixed diet, weight loss is primarily
decreased caloric intake, these diets offer an advantage. If due to loss of body fat (23). After several weeks, subjects
subjects lose weight on these diets, or even gain some who stay on a ketogenic diet regain water equilibrium
weight back when the diet ends (57), these diets might still (25). Because they restrict calories, low-CHO diets result
be of long-term benefit. Astrup and Rössner (77) concludes in loss of body fat if the diets are maintained for a longer
that a greater initial weight loss improves long-term main- period of time. A 4.5% reduction in body fat was reported
tenance, so long as the weight loss is followed by 1 to 2 in individuals consuming low-CHO diets for 10 weeks
years of an integrated weight maintenance program consist- (45). Golay et al. (21,22) reported significant body fat
ing of dietary change, behavior modification, and increased reduction (16.8% to 21.6%) in obese subjects consuming
physical activity. 15%, 25%, or 45% CHO isocaloric diets for 6 and 12
Body Composition Changes weeks. Losses of protein and fat are about the same
During the early days of a ketogenic diet, weight loss during a ketogenic diet as during an isocaloric, nonketo-
is partly due to water loss (25,55,78). In contrast, during genic diet (21,22,25).

Table 7. Nutrition analysis of various diets: Carbohydrate Addict’s, Sugar Busters!, Weight-Watchers, and Ornish
Diets
Carbohydrate Sugar Weight Watchers Ornish RDAs, DRVs,
Nutrient Addict’s diet Busters! diet diet DRIs*
Total calories 1476 1521 1462 1273 2000–2200
Moisture (H2O), g 746 1696 1200 1993 none
Total fat, g (% total kcal) 89 (54) 44 (26) 42 (25) 13 (9) 65 (30)
Saturated fat, g 35 11 9 2 20
Monounsaturated fat, g 31 20 18 3 20
Polyunsaturated fat, g 15 9 9 5 20
Cholesterol (mg) 853 128 116 4 300
Total protein, g (% total kcal) 84 (23) 89 (23) 73 (20) 48 (15) 75 (15)
Total CHO, g (% total kcal) 87 (24) 176 (46) 207 (56) 258 (81) 55–60%
Alcohol, g 0 14 0 2 moderation
Dietary fiber (g) 8 25 26 38 20–35
Vitamin E (mg) 7 7 29 7 15
Vitamin A (RE) 3039 948 5638 2318 700
Thiamin (mg) .8 2.4 3.0 1.8 1.1
Riboflavin (mg) 1.8 1.7 3.6 1.5 1.1
Niacin (mg) 16.4 32 37 17 14
Vitamin B6 (mg) 1.8 2.6 4.0 2.5 1.3
Folate (␮g) 176 377 636 615 400
Vitamin B12 (␮g) 6.5 3.4 11.6 1.0 2.4
Vitamin C (mg) 53 109 207 380 75
Calcium (mg) 640 712 1147 1053 1000
Phosphorus (mg) 1150 1510 1432 1181 700
Magnesium (mg) 173 400 325 477 320
Iron (mg) 8.2 20 28 24 18
Zinc (mg) 11 11 23 8 8
Sodium (mg) 3192 4012 2243 3358 2400
Potassium (mg) 2479 3020 3773 4026 3500
RDAs, Recommended Dietary Allowances; DRVs, Dietary Reference Values; DRIs, Dietary Reference Intakes.
Note: Items in bold indicate values different from RDAs, DRVs, and DRIs.
* RDAs and DRIs used are those of a female, 31–50 years old. Calculated values (DRV) are based on a 2000 kcal diet based on 30% total
calories from fat, 10% of total calories from saturated, monounsaturated, and polyunsaturated fat, and 15% total calories from protein.
2. Nutritional Analysis
Evidence Statement: In the short-term, low-CHO
● What is the nutritional profile of high-fat, low-CHO
ketogenic diets cause a greater loss of body water
than body fat. Water weight is regained when the diet diets?
● Do these diets provide adequate levels of nutrients,
ends. If the diet is maintained long-term, it results in
loss of body fat. Evidence Category C. based on current dietary recommendations?
Tables 6 and 7 are nutritional analyses of 1-day menus of
popular diets (presented in Tables 8 and 9), and a diet based
In conclusion, calories count, and low-CHO diets fail to on the USDA Food Guide Pyramid. Menus came from
confer a metabolic advantage with respect to body weight or books (48, pp. 338 –340; 49, pp. 147–164; 50, pp. 209 –217)
body composition. and a representative diet based on the Food Guide Pyramid.

Table 8. Dr. Atkins’ New Diet Revolution: menu items compared to the USDA Food Guide Pyramid
Meal Atkins’ induction Atkins’ ongoing Atkins’ maintenance Food Guide Pyramid
Breakfast • 2 scrambled eggs • 3 egg Western omelet • 2 egg spinach & cheese • 1 C orange juice
• 2 strips bacon (with milk, butter, omelet • 1 C Total cereal with 3/4
• Decaffeinated coffee peppers, onions, ham) • 2 CHO g bran crisp C skim milk
• 3 oz. tomato juice bread, 1 T butter • Coffee with 1 oz. 1%
• 2 CHO g bran crisp • 1/2 cantaloupe milk
bread
Snack • 6 oz. apple juice
Lunch • Bacon (1 slice) • Chef’s salad with 1 hard- • 4 oz. roast chicken • Turkey sandwich (3 oz.
cheeseburger (4 oz; 1 boiled egg, 2 oz. ham, 1 • 2/3 C broccoli meat, 1 T mayonnaise,
oz cheese) oz. cheese, 2 oz. chicken • Green salad with creamy tomato)
• Small salad (no dressing) • Iced tea Italian dressing • 10 baby carrots
• Seltzer water • 1 C milk (1%)
Snack • 1 C deep-fried pork • 10 saltine crackers
rinds (low-salt)
• 6 oz. V-8 (no-salt added)
Dinner • Clear consommé • 3 oz. poached salmon • Salad w/tomatoes, • 3 oz. Atlantic salmon
• 1.5 C shrimp salad • 3/4 C spinach onions, carrots • 1/2 C rice
• Steak (4 oz) • 1/2 C strawberries with • 1 C green beans • 1/2 C zucchini
• Salad with dressing 1 T heavy whipping • 1/2 small baked potato w/parmesan cheese
• 1 C Sugarless Jell-O cream w/sour cream, chives • 1 slice whole wheat bread
with 1 T whipped • 5 oz. loin of veal with 1 T canola margarine
sugar-free cream • 1 C fresh fruit salad
• 5 oz. white wine
Snack • 4 oz. Swiss cheese, 3 • 6 gingersnaps, 1 banana
slices of bacon, fried • 1/2 C chocolate ice cream
Diets are compared with current Recommended Dietary protein (25% to 30%) and fat (55% to 60%). Because overall
Allowances (RDAs) and Dietary Reference Intakes (DRIs). caloric intake decreases on low-CHO diets, and consumption
All food records were analyzed using the USDA 1994 to of protein and fat is self-limiting (11), the absolute amount of
1998 Continuing Survey Nutrient Database. protein and fat is not as high as these percentages imply.
Analyses reveal high-fat, low-CHO diets are also low in However, the absolute amount of these nutrients are higher in
calories (e.g., 1152 to 1627 kcal/d). The Atkins’ Maintenance low-CHO as compared with the typical American diet (105 g
Diet, to be followed after weight loss, provides 1990 kcal/d. vs. 82.5 g of protein and 94 g vs. 85 g of fat, low-CHO vs.
Low-CHO diets are high in fat, especially saturated American diet, respectively) (Table 3). When low-CHO diets
fat, and cholesterol. They are also high in protein (mainly are compared with moderate-fat, balanced nutrient reduction
animal), and provide lower than recommended intakes of diets, they provide twice as much protein and 2.4 times more
vitamin E, vitamin A, thiamin, vitamin B6, folate, cal- fat at the same caloric level.
cium, magnesium, iron, potassium and dietary fiber.
3. Metabolic and Adverse Effects
● What are the metabolic effects of high-fat, low-CHO
Evidence Statement: High-fat, low-CHO diets are diets?
nutritionally inadequate, and require supplementa- ● Will these diets correct the complications of diabetes,
tion. Evidence Category C. heart disease, and high blood pressure?
● What effects, if any, do these diets have on bone health,
cancer risk, and renal function?
Low-CHO diets are often referred to as high-protein or ● Are there any adverse effects when consuming these
high-fat diets because of the high percentage of calories from diets?

A number of different metabolic effects have been re- with high potential renal acid load leads to calciuria,
ported for high-fat, low-CHO diets. The most common is which adversely affects bone, unless buffered by the
ketosis, as measured by increased urinary ketones consumption of alkali-rich foods (e.g., fruits and vegeta-
(24,57,58,60,63,69,79). Ketogenic diets usually have less bles). Recently, New et al. (89) found that potassium,
than 20% calories from CHOs (80). Because many of these magnesium, fiber, ␤-carotene and vitamin C, and a high
are also low calorie, average CHO intake is 50 to 100 g/d. intake of fruit was important to bone health. Low-CHO
All popular low-CHO diets recommend ⬍100 g of CHO per diets, often providing inadequate amounts of these nutri-
day. Ketogenic diets may cause a significant increase in ents (and foods) may pose long-term risks to the skeleton.
blood uric acid concentration (57,60,63,67,78). The effect of high protein intake on renal function during
Other metabolic effects range from decreased blood weight loss induced by high- (25%) vs. low-protein (12%),
glucose and insulin levels, to altered blood lipid levels moderate-fat (30%) diets in overweight subjects over 6
(Table 10). Many of these effects (e.g., decreased LDL months was assessed by Skov et al. (90). Protein intake in
and HDL cholesterol) may be the consequence of weight the low-protein group decreased from 91 to 70 g/d, and
loss, rather than diet composition, especially considering increased from 91 to 108 g/d in the high protein group.
that the absolute amount of fat consumed on the low- Results indicate moderate changes in dietary protein intake
CHO diet may be similar to that consumed before the diet caused adaptive alterations in renal size and function with-
(Table 3). out indications of adverse effects. However, CHO content
of diet was not restricted (e.g., 45% or 58%) so this study
did not directly speak to the issue of a high-protein, high-fat,
Evidence Statement: High-fat, low-CHO diets re- and low-CHO diet. For further information on metabolic
sult in ketosis. Evidence Category B. consequences of high-protein intake see Metges and
Evidence Statement: Low-CHO diets that result Barth (91).
in weight loss may also result in decreased blood lipid Finally, low-CHO diets are often low in fruits, vegeta-
levels, decreased blood glucose and insulin levels, bles, and dietary fiber. This raises the specter of increased
and decreased blood pressure. Evidence Category C. cancer risk if such diets are consumed long-term (92–95).
However, because no long-term consumption data exist, it is
currently impossible to assess cancer risk in individuals
Possible effects of such high saturated fat diets on endo- consuming low-CHO diets.
thelial dysfunction need to be assessed. It has been proposed
that a single high-fat meal transiently impairs conduit vessel Adverse Effects
endothelial function (81). However, this hypothesis has Few clinically significant adverse effects have been re-
been recently challenged (82). ported in subjects consuming high-fat, low-CHO diets.
If excess weight causes complications of diabetes, heart Some reported side effects include bad taste in mouth
disease, and high blood pressure, then individuals who lose (57), constipation (70), diarrhea (49,56,72), dizziness (66),
weight on low-CHO diets, and maintain weight loss, may halitosis (57), headache (66), insomnia (49), nausea
see health benefits. However, no data support long-term (56,66,74), thirst (57), and tiredness, weakness, or fatigue
adherence to such diets, and high-fat, low-CHO diets con- (49,56,57,64,74).
tradict all governmental and nongovernmental dietary rec- Only one study assessed cognitive effects of low-CHO
ommendations with respect to reducing risk, or treating diets (69). Performance on attention tasks did not differ as
such conditions. a function of diet. Performance on the trail making task, a
neuropsychological test that requires higher order mental
Bone Health, Cancer Risk, and Renal Function processing and flexibility, was adversely affected by the
The potential effect of low-CHO diets on bone health ketogenic diet. Worsening of performance was observed
is an important consideration. In a study of diet and primarily between baseline and Week 1 of the diet.
osteoporosis, Wachman and Bernstein (83) hypothesized
the role of the skeleton in acid-base homeostasis in 4. Hunger and Appetite: Compliance, CHO Cravings,
adults, observing a reservoir of alkaline salts of calcium and Addiction
as key to the regulation of pH and plasma bicarbonate
● Do low-CHO ketogenic diets decrease hunger?
concentrations (see also 84 – 86). New (87), after review-
● What data support compliance to a low-CHO diet?
ing other studies showing that acidification increases the
● Are CHOs addictive?
activity of osteoclasts and inhibits that of osteoblasts,
concluded that a diet high in meat but low in fruits and Dietary adherence is one of the most difficult challenges
vegetables could lead to bone loss. Barzel and Massey faced by obese dieters (54). The stronger the feeling of
(88) concluded that excessive dietary protein from foods hunger, the greater the urge to break the diet. If diet com-

Table 9. Menu items of various diets: Carbohydrate Addict’s Diet, Sugar Busters!, Weight Watchers, and Ornish
Diets
Meal Carbohydrate Addict’s Sugar Busters! Weight Watchers diet Ornish diet
Breakfast • 3 egg onion-cheese (1 • 3/4 C grapefruit juice • 1 oz. Total Corn flakes, • 1/2 grapefruit
oz. cheese) omelet • 1 pkg instant oatmeal, 1/2 C non-fat milk • 1 package oatmeal, 1 oz.
(made with whole milk 2/3 C skim milk • 1 slice whole wheat raisins
and margarine) • Coffee bread, 1 pat margarine • 1 C skim milk
• 2 sausage links • orange • Brewed tea
• Coffee or tea
Snack • None allowed • 3 rye crispbread with 1 • 1 apple • apple
T peanut butter
Lunch • 1/2 C water-packed tuna • Turkey (3 oz.) sandwich • 2 oz. roast beef on rye • 1 corn tortilla, 2 T salsa,
salad (mayonnaise, on whole wheat bread bread 1/2 C black beans,
scallion and eggs) with mustard, lettuce, • 2 raw carrots 1/2 C canned tomatoes,
• 1 C salad tomato • tossed green salad, low- onions, 1/4 C green
• Diet cola calorie French dressing peas
• 1 cup non-fat milk • 1 C salad, 1/4 cantaloupe
• 10 grapes
Snack • None allowed • Apple • 1 ounce almonds
• 1 fig bar
Dinner • 3 oz. steak • 4 oz. pork tenderloin • 1 C beef bouillon soup; • 1 C brown rice with
• Baked potato with sour broiled with chopped 2 saltines 1/4 C tofu, stir-fry
cream and chives onion • 2.5 oz. salmon, broiled vegetables (1/2 C
• 1.5 C salad with 1 T • 1/2 C brown rice made • 3/4 C zucchini broccoli, 1/8 C cabbage,
buttermilk dressing, 1 with fat-free chicken • 1/2 baked potato 3 scallions, 1/8 C bean
raw carrot broth sprouts, 1/8 C peppers,
• 1/2 butter pecan ice • 1/2 C green beans 1/4 C snow peas, 1/8 C
cream • 1 C salad carrots); teriyaki sauce,
• 5 oz. red wine 2 oz. cooking wine, 1/4
t sesame seeds, 1/4 C
pineapple
• 1 C salad with no-oil
salad dressing
• 1 orange
Snack • None allowed • 12 nuts (mixed) • 1/2 C chocolate ice • 1/2 C strawberries
cream
• 1/2 C non-fat milk
position affects feelings of hunger, it may influence the g/d) effective in controlling hunger, and that hunger was not
ability of patients to adhere to the weight-loss regimen. a problem after the first week. Cedarquist et al. (65) wrote
Atkins claims the low-CHO diet is a revolution because no “subjects had a feeling of well-being and satisfaction. Hun-
hunger is experienced (48, pp. 112–113). Individuals are ger between meals was not a problem.” Krehl et al. (63)
allowed to eat as much protein and fat as they desire as long reported the highest level of satiation on a 12-g CHO diet
as they avoid CHOs. Atkins believes this combination of with a 70:30 ratio of fat to protein compared with diets
nutrients has a high satiety value and results in individuals having 60:40, 50:50; 40:60; or 30:70 ratios. (Note: this
eating less (and losing weight). In studies lasting up to 16 70:30 ratio is close to the Atkins’ ongoing weight loss
weeks, data indicate subjects consuming low-CHO diets phase, which has a ratio of fat to protein of 60:30.).
decrease food intake and lose weight (Tables 5a,b). Young Not all studies support these findings. Baron et al. (70)
et al. (64) found each of the low-CHO levels (30 g to 104 found that low-CHO dieters complained of hunger with the

Table 10. Reported metabolic effects of low-CHO, ketogenic diets

Clinical measure Increased Decreased No change
Blood uric acid 57,60,63,67 11
Blood glucose 21,22,60,67 24
Blood insulin 21,22,60
Blood glucagon 60
Glucose tolerance 60,79
SGOT 67
SGPT 67
Serum albumin 60
Blood urea nitrogen 45 79
Sodium balance 62 63,64
Potassium balance 64 63
Blood cholesterol 56 11,57
HDL cholesterol 21,57 [women only], 60 22,57 [women only], 60
LDL cholesterol 57 [women only] 60
Blood TG 21,45,57 [men only], 60,61,63,67 11,56
Blood pressure 22,67
Blank cells indicate no published data; numbers refer to studies cited.
same frequency as low-fat dieters. Worthington (66) re- Most studies on low-CHO diets (or of subjects receiving
ported no difference in acceptability, appetite, or satiety advice to consume low-CHO diets) were of short duration
after 2 weeks on either low-CHO or balanced diets, and and had small sample sizes (Tables 5a,b). Of studies pub-
ketosis did not suppress appetite. Rosen et al. (96,97) found lished over the last 44 years, those that lasted 9 weeks or
no support for the idea that a minimal-CHO, protein-sup- longer included a total of 76 subjects (21,45,57,64,65).
plemented fast (800 kcal; 58% protein, and 42% fat) de-
Are CHOs Addictive?
creases appetite and elevates mood in comparison with an
Some authors state that “CHOs are addictive” (50,51).
isocaloric CHO-containing diet that minimized ketosis.
Furthermore, they speculate that hyperinsulinemia prevents
Thus, the effect of low-CHO diets on hunger and satiety
a rise in brain serotonin, leading the CHO craver to feel
remains controversial.
hungry and eat more CHOs. This vicious cycle of hunger,
Compliance CHO craving, CHO consumption, and hyperinsulinemia is
Although compliance was not directly assessed, some proposed to be the underlying cause of obesity (50,51).
data indirectly apply to this issue. Kekwick and Pawan (24) Some confuse the matter further by stating, “certain people
fed patients low-calorie diets containing either 90% calories have a natural, overwhelming desire for CHO that doesn’t
from fat, protein, or CHOs. They noted, “Many of these correlate to hunger. These people in all likelihood have a
patients had inadequate personalities. At worst they would genetic predisposition toward CHO craving . . . which can
cheat and lie, obtaining food from visitors, from trolleys be reduced for some by embarking on a low-CHO diet” (51,
touring the wards, and from neighboring patients. (Some p. 118). The latter suggests that a change in dietary com-
required almost complete isolation). A few found the diet so position will override a purported genetic defect. Research
trying they could not eat the whole of their meals. When this has not substantiated any of these contentions.
happened, the rejected part was weighed, and the equivalent Wurtman (98) characterized self-selected, obese, “CHO
calories and foodstuffs were added to a meal later in the day. cravers” by their powerful and frequent cravings for and
A considerable number of failures in discipline were dis- consumption of foods rich in CHO over those high in
carded.” Rabast et al. (67,68), who studied subjects on a protein, especially during the afternoon snacking period.
metabolic ward receiving low-calorie, low-CHO liquid for- This snacking among obese CHO-cravers represents a vari-
mula diets, reported that after 30 days, “conditions for able that contributes to excess caloric intake (and weight),
comparative investigations were no longer met because the and became the basis for The Carbohydrate Addict’s Diet
two groups were declining rapidly.” No explanation for (50). This diet limits daily food intake to two “Complemen-
dropouts was given. tary” high-fiber, low-fat, low-CHO meals (how is that pos-

sible?) and one “Reward Meal” of unlimited quantity or and Schwartz et al. (106) indicated that insulin resistance
quality, consumed within 60 consecutive minutes. No and hyperinsulinemia predicted decreased weight gain over
snacks are allowed. The authors claim that eating “Comple- 3 years in glucose-tolerant adult Pima Indians. In contrast,
mentary Meals” fools the body into producing less insulin, Sigal et al. (107) reported hyperinsulinemia predicts in-
relative to what it would have produced if CHOs were creased weight gain. However, this study was questioned on
consumed at each meal. The claim that insulin output will the basis of subject sampling and methodology (33). Even if
be low no matter what is consumed at the “Reward Meal” so hyperinsulinemia is the cause of the metabolic imbalance, is
long as it is limited to 1 hour (50, p. 96) is unsubstantiated there evidence to show that low-CHO diets are better for
(and if true, potentially dangerous). This diet works simply weight loss than high-CHO diets?
because eliminating snacks and after-dinner eating results in Energy restriction, independent of diet composition (e.g.,
decreased caloric intake. 15% to 73% CHO) improves glycemic control (21,31–33).
If CHO cravings were due to decreased serotonin, then The ability to lose weight on a calorically restricted diet
drugs that increase serotonergic output should alleviate over a short-time period does not vary in obese healthy
cravings and result in decreased food intake. Early studies women as a function of insulin resistance or hyperinsulin-
with the serotonergic drug fenfluramine showed effective- emia (104). Although diet composition may play a role in
ness in decreasing CHO intake (99). However, the effect absolute reduction in blood insulin levels, weight loss seems
was not limited to CHO; it resulted in decreased intake of to be independent of such changes. For example, Golay et
protein as well (100). Toornlivet et al. (101,102) demon- al. (21) reported subjects consuming isocaloric diets (1000
strated that obese CHO cravers and non-CHO cravers re- kcal) containing 15% CHO had significantly lower insulin
sponded similarly to treatment with fenfluramine with re- levels as compared with those consuming 45% CHO, yet
spect to eating behavior and weight loss. Although the there was no difference in weight loss between the two
evidence may be interpreted to provide support for the groups. In another study, isocaloric diets (1200 kcal) con-
existence of a self-medication effect among a large segment taining 25% and 45% CHO resulted in similar reductions
of obese individuals, the mechanism by which CHO medi- in blood insulin levels as well as similar average weight
ates this effect has not yet been identified. Furthermore, a losses (22).
more likely interpretation is that some people simply have Grey and Kipnis (31) studied 10 obese patients who were
an unusually large appetite (i.e., they are cravers). fed hypocaloric (1500 kcal/d) liquid-formula diets contain-
Drewnowski (103) has pointed out that the so-called ing either 72% or 0% CHO for 4 weeks before switching to
“sweet-tooth” characterizing CHO cravers is just as much a the other diet. A significant reduction in basal plasma insu-
“fat-tooth” because the foods typically selected are high in lin levels was noted when subjects ingested the hypocaloric
both CHO (often sugar) and fat. Thus, the effect of low- formula devoid of CHO. Refeeding the hypocaloric, high-
CHO diets on hunger, appetite, and satiety need further CHO formula resulted in a marked increase in the basal
study. plasma insulin. However, patients lost 0.75 to 2.0 kg/wk
4a. Role of Insulin in Obesity irrespective of caloric distribution.
The effect of protein vs. CHO on blood insulin levels and
● Is overproduction of insulin, driven by high CHO in- subsequent weight loss was assessed by Baba et al. (32),
take, the cause of the metabolic imbalance that under- who studied 13 male obese hyperinsulinemic subjects for 4
lies obesity? weeks. They were fed a hypoenergetic diet (comprised of
● If so, can obese, hyperinsulinemic individuals lose 80% of the person’s resting energy expenditure) containing
more weight on low-CHO diets as compared with either 25% CHO and 45% protein, or 58% CHO, and 12%
high-CHO diets? protein. Both diets contained 30% calories from fat. Despite
● Does leptin interact with insulin in regulation of appe- the significant, but not different degrees of reductions in
tite and body weight? blood insulin levels that occurred on both diets, the insulin
Dietary CHO, as well as dietary protein, increases insulin levels were reduced to within the normal range only in the
secretion. The hyperinsulinemia of obesity may be the result high-protein group. Although individuals in both groups
of dietary factors, genetic factors (e.g., “thrifty genotype”) lost weight, the mean weight loss was significantly higher
or secondary adaptation to insulin resistance (31). Increased on the high-protein as compared with the high-CHO diet, a
appetite and consequent overconsumption may drive in- consequence, perhaps, of the higher protein, lower CHO
creased insulin, but as body weight increases, and insulin content of the diet.
resistance develops, this too will drive increased The optimal macronutrient composition of a weight-re-
insulin secretion. ducing regimen in obese hyperinsulinemic patients is the
The relationship between insulin resistance and weight subject of research, but beyond the scope of this article (for
gain yield conflicting results (104). Swinburn et al. (105) more information see Reaven et al. (108)).

Insulin and Leptin in the Endocrine Regulation of Recent studies show consuming a high-fat diet induces
Appetite and Body Weight resistance to the actions of leptin to decrease food intake
Insulin and leptin are hormones that act as medium- to (122,123), and that increased energy intake and weight
long-term regulators of body weight through their actions to gain is related to an impairment of insulin transport into
decrease food intake and increase energy expenditure (met- the brain (124). Therefore, dietary macronutrient compo-
abolic rate), ensuring that energy intake and energy expen- sition affects not only production of insulin and leptin but
diture is closely matched (109 –111). also may influence their ability to gain access to the brain
People who do not produce leptin due to a genetic defi- to signal target neurons. In studies investigating the ef-
ciency, or who have defects in the leptin receptor, have ficacy and long-term consequences of weight loss diets, it
dramatically increased appetites and overeat to the point of is important to consider the effects of dietary macronu-
becoming massively obese (112,113). The effects of leptin trient content and composition on the production of in-
deficiency are ameliorated by the administration of recom- sulin and leptin, and their actions to regulate energy
binant leptin (114). intake and expenditure.
Insulin, in addition to its effects in the central nervous 5. Performance and Physical Activity
system to inhibit food intake, acts in the periphery to ensure
● Does the low-CHO diet affect physical performance?
the efficient storage of incoming nutrients. The role for
insulin in the synthesis and storage of fat has obscured its Although reference is made to physical activity and
important effects in the central nervous system, where it acts exercise by proponents of low-CHO diets (48, pp. 260 –
to prevent weight gain, and has led to the misconception that 267; 49, pp. 187–206; 50, pp.143–144), only one study
insulin causes obesity (115). It has recently been shown that examined the capacity for moderate exercise in obese
selective genetic disruption of insulin signaling in the brain subjects after adaptation to a hypocaloric, ketogenic diet.
leads to increased food intake and obesity in animals This study was conducted in six slightly to moderately
(116) demonstrating that intact insulin signaling in the overweight, untrained subjects on a protein-supple-
central nervous system is required for normal body weight mented fast for 6 weeks (e.g., 500 to 750 kcal/d, ⬍10 g
regulation. CHO, weight loss, 10.6 kg). Results indicate that subjects
Insulin also has an indirect role in body weight regulation adapt to prolonged ketosis and use lipid, rather than
through the stimulation of leptin (117). Both insulin and CHO, as the major metabolic fuel during prolonged ex-
leptin are transported into the central nervous system, where ercise at 60% of maximum oxygen concentration. This
they may interact with a number of hypothalamic neuropep- shift was confirmed by an respiratory quotient of 0.66
tides known to affect food intake and body weight (118). during exercise (125).
Insulin and leptin are released and circulate in the blood- Other studies were conducted in physically untrained,
stream at levels that are proportionate to body fat content. but normal weight males who were fed eucaloric low-
Secretion and circulating levels are also influenced by CHO (⬍20 g/d), high-fat (80%) ketogenic diets, or non-
amount and type of foods eaten, with decreased concentra- ketogenic, low-, medium-, or high-fat diets (15%, 30%,
or 55% fat) (126,127). They report diet manipulation, per
tions noted during fasting or energy-restricted diets
se, did not effect maximal or submaximal aerobic per-
(119,120). The decrease of leptin during a prolonged ener-
formance in untrained individuals. However, one cannot
gy-restricted diet has been shown to be related to increased
extrapolate results from these studies to typically un-
sensations of hunger (120) suggesting a role for low leptin
trained, sedentary, overweight individual consuming
levels to increase appetite during dieting in humans, and
low-calorie, low-CHO diets.
therefore to the predisposition for weight regain after ini-
tially successful dieting.
Circulating concentrations of both insulin and leptin, II. Moderate-Fat, Balanced Nutrient
measured over a 24-hour period, are reduced in women Reduction Diets
consuming high-fat meals (60% fat, 20% CHO) compared Moderate-fat, balanced nutrient reduction diets contain
with when equicaloric meals high in CHO and low in fat 20% to 30% fat, 15% to 20% protein, and 55% to 60%
(60% CHO, 20% fat) are consumed (36,37). Increased in- CHO. Popular diets in this category include those promoted
sulin secretion has been suggested to protect against weight by commercial weight loss centers (e.g., Weight Watchers,
gain in humans (106). Because insulin also stimulates leptin Jenny Craig, Nutri-Systems). These diets have a long his-
production, which acts centrally to reduce energy intake and tory of use, millions of followers worldwide, and are typi-
increase energy expenditure, decreased insulin and leptin cally based on sound, scientific principles. The DASH diet,
production during the consumption of high-fat diets could diets based on the USDA Food Guide Pyramid, and the
help contribute to the obesity promoting effects of dietary National Cholesterol Education Program Step I and Step II
fat (42,44,121). Diets also fit into this category if calories are reduced (128).

Table 11. Relation between dietary fat intake (20% to 30% kcal) and weight change in overweight subjects
Energy Energy Energy Weight Weight
Duration Fat g start end change change change
Study n BMI (weeks) (%) (kcal) (kcal) (kcal) (kg) (g/day)
Buzzard (132) 17 28.6 13 35 (23) 1840 1365 475 ⫺2.8 ⫺31
Carmichael (133) 39 35 0–17 40 (22) 2177 1608 (569) ⫺3.0 ⫺25
17–26 46 (25) 2177 1658 (519) ⫺2.6 ⫺21
Golay (22) 21 38 6 30 (26) N/A 1027 N/A ⫺7.0 ⫺167
Golay (21) 37 33 12 34 (26) N/A 1178 N/A ⫺9.0 ⫺100
Hammer (134) 4 37 16 37 (23) 1934 1450 (484) ⫺5.8 ⫺52
Harvey-Berino (40) 29 30 24 45 (27) 2171 1477 (694) ⫺11.8 ⫺70
28 24 38 (21) 1929 1650 (279) ⫺5.2 ⫺31
Insull (135) 184 68.8 26 31 (21) 1734 1316 (418) ⫺3.16 ⫺17
173 52 31 (22) 1734 1299 (435) ⫺2.93 ⫺8
Henderson (136) 163 104 34 (23) 1734 1355 (379) ⫺1.91 ⫺3
Jeffery (137) 39 31 26 36 (23) 1506 1125 (391) ⫺4.6 ⫺25
52 40 (26) 1506 1112 (394) ⫺2.1 ⫺6
78 40 (26) 1506 1199 (307) 0.4 1
Knopp (131) 57 28 52 63 (28) 2395 2019 (356) ⫺2 ⫺5
55 27 52 58 (26) 2294 1995 (299) ⫺2 ⫺5
62 28 52 52 (25) 2281 1917 (364) ⫺6 ⫺16
Pascale (138) 15 N/A 16 30 (22) 1658 1201 (457) ⫺7.7 ⫺69
16 16 31 (22) 2024 1246 (778) ⫺7.5 ⫺67
Powell (20) 8 20% 12 26 (20) 1642 1163 (479) ⫺5.0 ⫺60
9 above IBW 12 37 (28) 2081 1190 (891) ⫺4.6 ⫺55
Prewitt (139) 6 38 1–4 70 (37) 1894 2047 153 ⫺1.5 ⫺53
5–20 58 (21) 2047 2428 381 ⫺0.6 ⫺5
Puska (140) 35 28% body fat 6 51 (23) 2490 2001 (489) ⫺0.7 ⫺17
Rumpler (141) 4 28% body fat 4 34 (20) 3095 1542 (1553) ⫺5.0 ⫺178
Shah (142) 47 31 26 37 (21) 1893 1580 (313) ⫺4.4 ⫺24
Skov (143) 23 30 0–13 80 (29) N/A 2533 N/A ⫺5 ⫺54
13–26 86 (29) 2533 2676 143* ⫺5 ⫺27
Swinburn (144) 49 30 52 52 (26) 2195 1832 (369) ⫺3.1 ⫺8
N/A, Not available.

Adapted from Bray G and Popkin BM (42).
* Weight loss occurred from 0 –13 weeks, and no further weight was lost from 13–26 weeks. Caloric intake was not significantly different
during the two time periods. Actual caloric intake is suspect based on methodology.
However, most consumers (and governmental agencies) do the reduction of saturated fat and cholesterol, these diets
not perceive the latter as “popular diets,” probably because also promote weight control because obesity contributes to
they are typically promoted for reasons other than weight high blood cholesterol in many patients (128).
loss and because they are not promoted as commercial diets. Balanced nutrient reduction diets (moderate-fat, high-
For example, the DASH diet (35) has been shown to reduce CHO) used for weight loss have been studied extensively
hypertension, and the Food Guide Pyramid, in conjunction (6,18,42).
with the Dietary Guidelines, provides recommendations for
healthful eating. Although the main focus of the National
Cholesterol Education Program Step I and Step II diets is

Table 12. Change in body weight, overall caloric intake, and diet composition in studies that evaluated the efficacy
of low-fat, ad libitum diets (LFAL) vs. low-energy (LE) diets for weight loss*
Shah (142) ⌬ BW (kg) Calories Fat g (%) CHO g (%) Protein g (%)
LFAL 4.4 1580 37 (21) 245 (62) 60 (16)
LE 3.8 1550 34 (30) 206 (54) 60 (16)
Jeffery (137) ⌬ BW (kg) Calories Fat g (%) CHO g (%) Protein g (%)
LFAL 1.9 1350 40 (26) N/A N/A
LE .5 1414 50 (32) N/A N/A
Schlundt (145) ⌬ BW (kg) Calories Fat g (%) CHO g (%) Protein g (%)
LFAL 4.6 1425 30 (19) 210 (58) 64 (18)
LE 8.3 1265 28 (19) 179 (58) 61 (18)
Harvey-Berino (40) ⌬ BW (kg) Calories Fat g (%) CHO g (%) Protein g (%)
LFAL 5.2 1650 38 (20) 251 (61) 69 (16)
LE 11.8 1477 45 (27) 200 (54) 60 (16)
N/A, Not available.

* Bold indicates the type of diet (in each study) that was more effective for weight loss. No difference between diets in the Shah paper.
A. Underlying Philosophy, Claims, and Proposed

Solutions Evidence Statement: Low-calorie diets* can re-
The underlying philosophy of moderate-fat, balanced nutri- duce total body weight by an average of 8% over 3 to
ent reduction diets is that weight loss occurs when the body is 12 months. Evidence Category A.
in negative energy balance. Diets are calculated to provide a Evidence Statement: Although lower-fat diets
deficit of between 500 to 1000 kcal/d, but a minimum number without targeted caloric reduction help promote
of daily calories (e.g., 1000 to 1200 for women, 1200 to 1400 weight loss by producing a reduced calorie intake,
for men) are recommended. Increased energy expenditure lowerfat diets coupled with total caloric reduction
(e.g., physical activity) is promoted as well. produce greater weight loss than lower-fat diets
The goal of moderate-fat, balanced nutrient reduction diets alone. Evidence Category A.
is to provide the greatest range of food choices to the con-
sumer, to allow for nutritional adequacy and compliance, while
still resulting in a slow but steady rate of weight loss (e.g., 1 to
2 lbs/wk). Programs are usually based on up-to-date, scientific The NHLBI concludes, “there is little evidence that low-
information. For example, recently Weight Watchers started a er-fat diets cause weight loss independent of caloric restric-
new program called the 10% difference, based on scientific tion.” This is supported by Powell et al. (20), who studied
findings that a 10% reduction of body weight improves health obese subjects consuming isocaloric reduced calorie diets
(e.g., decreases blood pressure, improves lipid profile, etc). A (1200 kcal/d) containing either 15%, 20%, 28%, or 34%
similar program is the Shape Up and Drop 10! program of calories from fat for 12 weeks. All subjects lost body weight
Shape Up America! (129). and body fat. However, there were no significant differ-
ences in the rate or amount of body weight or percent body
fat lost across the four groups during the intervention.
B. Scientific Evaluation of Claims
Bray and Popkin (42) and Astrup et al. (43,121) reviewed
1. Caloric Intake, Body Weight, and Body Composition
the relationship between dietary fat intake and weight
● What is the effect of balanced nutrient reduction diets change extensively. Based on a meta-analysis of normal
on body weight and composition? weight and overweight subjects, Bray and Popkin con-
● Which is better for weight loss: reducing calories or cluded a 10% reduction in the percentage of energy from fat
reducing fat? would reduce body weight by 16 g/d†. Table 11 summarizes
The NHLBI evidence report Clinical Guidelines on the Iden-
tification, Evaluation, and Treatment of Overweight and Obesity * Low-calorie diets contain 1000 to 1200 kcal/d.
in Adults reviewed the effects of dietary therapy on weight loss † The meta-analyses by both Bray and Astrup included normal weight and overweight
(6). Key evidence statements from that report follow. individuals.

Table 13. Effect of low-fat ad libitum diets (LFAL) vs. low-energy diets (LE) on caloric intake, diet composition
and change in body weight
Calories Fat CHO Protein
⌬ BW
Diet (kg) Start End ⌬ ⌬g ⌬% ⌬g ⌬% ⌬g ⌬%
Shah (142): Data from 6 months.
Conclusion: No difference between groups at 6 months.
LFAL 4.4 1893 1580 313 ⫺39 ⫺13 ⫺1 ⫹11 ⫺13 ⫹0.7
LE 3.8 2119 1550 569 ⫺24 ⫺4 ⫺49 ⫹3.5 ⫺15 ⫹0.6

⌬ BW
Jeffery* (137): Data from 12 months.
Conclusion: Low-fat better at 12 months; no difference at 18 months.
LFAL 2.1 1735 1350 385 ⫺31 ⫺11 N/A N/A N/A N/A
LE .5 1774 1414 360 ⫺20 ⫺4 N/A N/A N/A N/A

⌬ BW
Schlundt (145): Data from 16–20 weeks.
Conclusion: Low-energy better at 16–20 weeks, no difference at 9–12 months
LFAL 4.6 2200 1425 775 ⫺64 ⫺19 ⫺19 ⫹17 ⫺20 ⫹3
LE 8.3 2000 1265 735 ⫺59 ⫺20 ⫺12 ⫹19 ⫺38 ⫹2

⌬ BW
Harvey-Berino (40): Data from 24 weeks.
Conclusion: Low-energy better at 24 weeks. No long term follow-up available.
LFAL 5.2 1929 1650 279 ⫺26 ⫺9.2 ⫺3 ⫹8.3 ⫺9 ⫹4.2
LE 11.8 2170 1477 693 ⫺33 ⫺5.1 ⫺75 ⫹3.6 ⫺23 ⫹1.1
N/A, Not available.

* Data was taken as the average of intakes reported by food frequency and food recalls.
the relationship between dietary fat intake and weight The retort may be “reduction in fat alone is not enough,
change in overweight subjects consuming 20% to 30% fat calories matter too!” (see Calories vs. Fat below). Second,
diets. Clearly, subjects who reduce fat intake reduce overall the reduction of fat to 27% may have accounted for the
caloric intake, and lose weight. Despite these data, Willett majority of weight loss effects and that further reductions
(130) argues that the relationship between dietary fat and provide minimal additional benefit (e.g., there may exist a
obesity is unconvincing. In support, Knopp et al. (131) is threshold of dietary fat below which changes in body weight
cited. In this study, moderately overweight hypercholester- are minimal) (44). In reality, the study by Knopp et al. (131)
olemic men were randomly assigned to one of four levels of supports the relationship between fat intake and body
dietary fat for 1 year. Despite differences in actual fat intake weight. When fat decreases from 34% to 36% to less than
in the seven diet groups (ranging from 22% to 28% fat), all 30%, caloric intake significantly decreases and results in
groups lost an equivalent amount of body weight (2 to 3 kg). significant body weight reduction. This occurs in all groups,
Willett (130) argues that if fat matters, then those consum- but is most pronounced in overweight subjects (BMI, 27)
ing 22% fat should lose more weight than those consuming who decreased fat intake from 34% to 25%, and who lost 6
28% fat. kg over the course of a year (16 g/d), as Bray and Popkin

Table 14. Effect of moderate-fat diets on changes in body composition

Study Duration Body fat (% change) LBM (kg) Waist circumference Hip circumference
Golay (22) 6 weeks 2 17 N/A 2 2
Golay (21) 12 weeks 25 N/A 2 2
Siggaard (39) 12 weeks 2 4.2 ⫹.25 N/A N/A
Prewitt (139) 20 weeks 2 2.3 ⫹8 N/A N/A
Carmichael (133) 6 months N/A N/A 2 2
Shah (142) 6 months 2 2.2 ⫺1.2 N/A N/A
Skov (143) 6 months Yes (4 kg)* N/A Yes N/A
N/A, Not available.

* % change not available.
(42) predicted. That there was not a significant difference in The nutritional profile of a balanced-nutrient reduction
total caloric intake and weight loss at levels of fat between diet (e.g., “Weight Watchers”) is presented in Table 7.
22% to 28% does not mean that reducing fat below 30% When proper food choices are made, these diets are nutri-
kcal does not make a difference in body weight; it does. tionally adequate (128, 146).
Calories vs. Fat

Which diet is better for weight loss: a low-fat ad libitum Evidence Statement: With proper food choices
(LFAL) or a low-energy (LE) diet? At present, data are insuf- based on the USDA Food Guide Pyramid the mod-
ficient to say that one is better: weight loss occurs on both. erate-fat, balanced nutrient reduction diet is nutrition-
Tables 12 and 13 are from studies in which subjects ally adequate. Evidence Category B.
consumed either LFAL or LE diets containing 19% to 30%
calories from fat (40,137,142,145). Both diets result in
However, if appropriate food choices are not made, diets
reduction of total caloric intake from fat, CHO and protein,
may fall short with respect to calcium, zinc, magnesium,
and both result in weight loss independent of diet compo-
iron, vitamin B12 and dietary fiber (132,135,144). Swinburn
sition. Studies reveal percent fat does not always correlate
et al. (144) studied the effect of reduced fat ad libitum diets
with calories, so that fat content of a diet, in and of itself,
over a 1-year period in 110 New Zealand adults. Nutrient
may not determine weight loss (131). Just because a diet is
intakes were derived from 3-day food diaries at the begin-
lower in fat does not mean it is lower in calories (40), and
ning and end of the study. Blood levels of retinol, ␣-tocoph-
two diets may be the same percent fat, but differ in caloric
erol, and ␤-carotene were determined at the end of the
content, resulting in differences in weight loss (145). Fi-
study. Results show that reduced fat intake (from 35% to
nally, studies show that what predicts short-term weight loss
25% of energy) led to reduced calorie intake and weight loss
may be different from what predicts long-term weight main-
compared with a usual diet (33% fat). There were no dif-
tenance.
ferences between the diets in changes in micronutrient in-
takes, except for an energy-adjusted increase in ␤-carotene
Body Composition intake in the reduced-fat group. Fiber intake remained at 20
The NHLBI concludes that low-calorie diets resulting in g/d. However, the calcium intake in both groups was low
weight loss decrease body fat. Subjects who consume mod- (⬃600 mg/d).
erate-fat, balanced nutrient reduction diets lose body fat, Buzzard et al. (132) indicated that intake of zinc and
and decrease waist and hip circumferences. The change in magnesium was significantly reduced in women with stage
lean body mass is inconsistent (Table 14). II breast cancer consuming reduced fat (22%) diets. Cal-
cium intake (628 mg/d) was similar to that reported by
2. Nutritional Analysis
Swinburn et al. (144), but this amount is less than two-thirds
● What is the nutritional profile of balanced-nutrient the recommended intake. Fiber intake (15 g/d) was also low.
reduction diets? Insull et al. (135) assessed dietary intake among women
● Do diets provide adequate levels of nutrients, based on consuming low-fat vs. control diets (22% vs. 37% fat,
current dietary recommendations? respectively). Despite similarities in dietary intakes between

groups, calcium, iron, and vitamin B12 intake was slightly 4. Hunger and Appetite: Compliance
below daily requirements, necessitating the use of dietary
● What is the effect of moderate-fat, balanced nutrient
supplements.
reduction diets on hunger and appetite?
● What data support compliance to these diets?
3. Metabolic and Adverse Effects
A number of studies in which subjects consumed
● What are the metabolic effects of moderate-fat, bal- LFAL diets report that individuals do not complain of
anced nutrient reduction diets? hunger, but rather, that there is too much food. Siggaard
et al. (39) reported a high degree of satisfaction with the
Studies allowing ad libitum intake of reduced-fat, high-
changes in food intake in Danish workers consuming a
CHO diets show the changes in blood lipids are dominated
LFAL diet for 12 weeks. Subjects stated, “I have never
by the slight weight loss induced by such diets (43). This
been eating as much as I do now” and “I have not felt
is confirmed by the systematic review of effects of the hungry at any time.” Shah et al. (142) reported subjects
National Cholesterol Education Step I and II dietary inter- consuming LFAL diets rated these higher than LE diets
vention programs on cardiovascular disease risk factors. in palatability, satiety, and quality of life measures. Jef-
Meta-analysis reveals these diets reduce LDL-chol- fery et al. (137) found that subjects asked to reduce fat
esterol, normalize plasma TGs, and normalize the ratio of were more compliant with treatment instructions, re-
HDL/TC (27). ported greater success in reaching their dietary goals, and
In studies reviewed here, Golay et al. (21,22) reported rated their diet as higher in palatability. They had greater
diets containing 26% fat (and either 1000 or 1200 kcal) decreases in binge eating scores than those in the LE
resulted in reduced TC, HDL cholesterol, and TGs. Skov et group.
al. (143) reported diets containing 29% fat (but 2600 kcal) In support of LE diets (over LFAL diets), Harvey-Berino
reduced TC and HDL but increased TGs. Theusen et al. (40) found that subjects consuming LE diets had more
(147) reported subjects consuming 21% fat diets containing positive changes in eating behaviors, and greater improve-
1835 to 2026 kcal for 1 year had decreased levels of total ments in feelings of physical wellness that were not corre-
and LDL cholesterol, no change in HDL cholesterol, and lated to weight loss. However, these diets were rated more
decreased TGs. Henderson et al. (136) measured changes in inconvenient than LFAL diets.
plasma TC among intervention group women at 12 and 24 Subjects consuming both LE and LFAL diets reported an
months, and reported TC decreased in the group consuming increased distaste of fat. Subjects in both groups reported
low-fat diets (22% fat) but not in those consuming control increased feelings of deprivation, but the changes in the
higher-fat diets (37% fat). group were not significant (40). Bray and Popkin (42)
Moderate-fat, balanced nutrient reduction diets reduce conclude adherence to an LFAL diet is a function of the
blood pressure (6,21,22,35). frequency of dietary counseling. This may be the case for
Only Golay et al. (21,22) measured fasting insulin levels, any reduced-calorie diet, regardless of macronutrient com-
which were significantly reduced in subjects who lost position. Alford et al. (45) remarked, “For the women in our
weight on balanced nutrient reduction diets. When moder- group, the interaction and support were the most important
ate-fat (20%) meals are consumed, postprandial insulin se- aspects. I think that is true for most women. We tried
cretion is enhanced and circulating leptin levels are in- to make the nutrition classes personal, so the women
creased over a 9-hour (37) or 24-hour (36) period. These wouldn’t tune them out.” Perhaps psychological issues
changes of insulin secretion and leptin production could are more important than dietary factors in the discussion
contribute to the effects of balanced nutrient reduction on compliance.
diets on energy intake, hunger and appetite, and energy Finally, The Women’s Health Trial Vanguard Study
expenditure. (135,136) examined the feasibility of a nationwide, ran-
domized multicenter intervention trial to test the hypoth-
esis that a low-fat diet followed for 10 years reduces
breast cancer risk. Feasibility studies of women at in-
Evidence Statement: Moderate-fat, balanced nu- creased risk show dietary intervention targeted to lower
trient reduction diets reduce LDL-cholesterol, nor- dietary fat below 25% can be implemented and main-
malize plasma TGs, and normalize the ratio of HDL/ tained successfully over a 2-year period. However, be-
TC. Evidence Category A. cause women in these studies were highly selected and
Evidence Statement: Moderate-fat, balanced nu- motivated, caution is urged in extrapolating compliance
trient reduction diets reduce blood pressure. Evidence data to the “dieting” public, whose motivation for reduc-
Category A. ing fat may be very different from those in this study
group.

Table 15. Relation between dietary fat intake (⬍10 –19% kcal) and weight change in overweight subjects
Fat g Energy Weight change Weight change
Study n BMI Duration (%) (kcal) (kg) (g/day)
Agus (152) 10 30.6 9 days 30 (18) 1493 ⫺3.23 ⫺358
Alford (45) 12 28 12 wk 13 (10) 1200 ⫺4.8 ⫺57
Barnard (155) 2643 ⬎30 3 wk 13 (10) 1200 ⫺5.1 ⫺242
1897 ⬎30 3 wk 13 (10) 1200 ⫺3.3 ⫺157
Djuric (150) 113 27.8 12 wk 35 (17) 1843 ⫺.9 ⫺10
57 (32) 1559 ⫺2.3 ⫺27
28 (18) 1392 ⫺3.6 ⫺42
Havel (34) 17 35.1 6 mo N/A (12) N/A ⫺4.0 ⫺21
8 mo N/A (11) N/A ⫺5.0 ⫺21
Heilbronn (33) 35 N/A 12 wk 18 (10) 1600 ⫺6.6 ⫺78
Kasim-Karakas (151) 54 27.6 6 mo 20 (12) 1449 ⫺2.5 ⫺13
8 mo 19 (11) 1503 ⫺3.1 ⫺13
10 mo 19 (12) 1420 ⫺3.3 ⫺11
12 mo 19 (12) 1474 ⫺4.6 ⫺13
Lissner (149) 12 ⬎101% 2 wk 40 (18) 2087 ⫺.4 ⫺28
MLI standards*
Noakes (28) 22 31 12 wk 17 (10) 1553 ⫺7.9 ⫺94
Ornish (156,14) 25 28.4 52 wk 13 (6) 1821 ⫺10.7 ⫺29
20 28.4 260 wk 17 (8) 1846 ⫺5.8 ⫺8
Powell (20) 8 20% above IBW 12 wk 19 (15) 1113 ⫺4.5 ⫺53
Schaefer (38) 27 (LFAL) 26.3 10–12 wk N/A (15) N/A ⫺3.63 ⫺43
Schlundt (145) 27 (LFAL) 31 16–20 wk 30 (19) 1425 ⫺4.6 ⫺32
29 (LE) 35 16–20 wk 28 (19) 1264 ⫺8.3 ⫺59
Surwit (153) 20 36 6 wk 13 (11) 1087 ⫺7 ⫺166
22 35 6 wk 14 (11) 1156 ⫺7.4 ⫺176
N/A, Not available.

* MLI is Metropolitan Life Insurance Tables.
III. Low-Fat and VLF Diets dietary fat and cholesterol based on the (now) well-known
(<10% to 19% Fat) association between saturated fat consumption and cardio-
vascular disease.
VLF diets are defined as containing ⬍10% fat, and low- However, as Americans became fatter, and their hunger
fat diets contain between 11% and 19% fat. Both are very for diet books remained unsatiated, proponents of VLF diets
high in CHO, and moderate in protein. Representative VLF (e.g., Ornish and Pritikin) capitalized on their program’s
diets are those promoted by Dr. Dean Ornish, and Nathan apparent effect on body weight. They changed the focus
and Robert Pritikin. There are no commercial diets that fit in (and title) of their books from heart disease to weight loss‡.
the category of low-fat diets, although there is research on Neither trial (e.g., The Lifestyle Heart Trial or The Pritikin
these diets meriting their inclusion in this paper. Program was originally designed to assess the effect of diet
The American consumer has traditionally ignored the
VLF diet for weight loss. It seems they would rather restrict
CHO intake to less than 10% of calories than to restrict ‡ This theory is supported by changing book titles over the past 20 years. Ornish’s book
titles include Stress, Diet and Your Heart (1982), Dr. Dean Ornish’s Program for Reversing
intake of their favorite fat (or sweet-fat combination) to the Heart Disease (1990), and Eat More, Weigh Less (1993). The Pritikin plan was originally
same degree. In addition, these diets were not historically popularized by Nathan Pritikin, whose books included The Pritikin Program for Diet and
Exercise (1979) and The Pritikin Promise (1983). His son, Robert, head of the Pritikin
promoted as weight loss diets, but rather, diets to prevent or Longevity Center wrote The New Pritikin Program (1990), The Pritikin Weight Loss
reverse heart disease. VLF diets recommended reduction of Breakthrough (1998), and The Pritikin Principle (2000).

Table 16. Energy intake from 0 –5 years (The Lifestyle Heart Trial)
Experimental Control p*
Baseline (B) 1 year 5 years Baseline 1 year 5 years B–1 year B–5 years
Energy intake 1950 1821 1846 1711 1673 1572 0.64 0.86
Energy change ⫺129 ⫺104 ⫺38 ⫺139
Body weight (kg) 91.4 80.64 85.64 75.74 77.18 77.09 0.001 0.001
* All p values are two-tailed and each is the result of a test of the null hypothesis that the change between two particular visits (e.g. baseline
and 1 year) does not differ between the experimental and control groups (14). Adapted from Ornish (14,156).
on weight loss. Thus, the scientific information on the effect B. Scientific Evaluation of Claims
of these diets on body weight and body composition is 1. Caloric Intake, Body Weight, and Body Composition
limited. In addition, caution in the interpretation of results is
● Do low-fat and VLF diets result in decreased caloric
necessary because diet is but one component of these total intake?
lifestyle-modification plans. ● What is the effect of these diets on body weight and
body composition?
A. Underlying Philosophy, Claims, and Proposed Solutions Overweight subjects who consume low-fat, and VLF,
Proponents of VLF diets support reducing caloric intake high-CHO diets eat fewer calories and lose weight
and increasing energy expenditure to achieve weight loss. (20,34,38,145,149,150 –152) (Table 15). Again, total ca-
Rather than counting calories, per se, dietary recommenda- loric intake is more important than diet composition, in this
tions focus on “type of calories” (13, p. 31) and “caloric case fat, for weight loss (28,33,45,154). In the context of
density” (17, p. 5). “Eat more, weigh less” (13) does not reduced caloric intake (1200 kcal/d) percent calories de-
mean, “eat more calories.” It means, “consume more high rived from fat (15% to 35%) does not influence weight loss
complex CHO, and high-fiber foods whenever you feel (20). Havel et al. (34) reports a family history of diabetes is
hungry and until you feel full, but not stuffed” to lose predictive of weight loss (and fat loss) in women consuming
weight (13, p. 32). The “calorie density solution” enables LFAL diets for 6 months.
individuals to eat as much as they want—six to seven times Subjects who lose weight on low-fat diets lose body fat
daily—and lose weight safely, gradually, and without hun- (120,34,45,151) and lean body mass (145). However, in the
ger (17, p. 17). These VLF diets are based primarily on context of a reduced calorie diet, the amount of dietary fat
vegetables, fruits, whole grains, and beans, with moderate (10% to 40%) does not affect losses of body fat or lean body
quantities of egg whites, nonfat dairy or soy products, and mass over 12 weeks (20).
small amounts of sugar and white flour. Ornish’s diet is
vegetarian; Pritikin allows a limited amount of low-fat
animal protein daily (no more than 3.5 ounces of lean beef, Evidence Statement: Overweight subjects con-
fowl or fish). suming low-fat, high-CHO diets eat fewer calories,
Dr. Dean Ornish’s Program for Reversing Heart Dis- lose weight, and lose body fat. Evidence Category A.
ease (148) and The Pritikin Program (15,16) promotes
lifelong changes in diet, exercise, and lifestyle. Each plan
includes a nutrition and exercise component; Ornish’s Alford et al. (45) fed adult, sedentary, overweight women
plan includes stress reduction and emotional support as reduced calorie diets (1,200 kcal/d) containing 10%, 35%,
well. Current claims range from weight loss, to overcom- or 45% calories from fat for 12 weeks. The 10% fat diet was
ing or reversing heart disease, reducing symptoms of type 70% to 80% CHO. Weight loss was the same on each diet.
2 diabetes, high blood pressure, cancer, arthritis, stress, Noakes and Clifton (28) fed 62 overweight subjects (mean
and smoking, in addition to general wellness, sometimes BMI ⬃31) one of three test diets for 12 weeks. One was
in as little as 2 weeks (13,15,16,148). Pritikin also claims VLF (10% fat), high-CHO (71.6%), whereas the other two
medications for heart disease, diabetes, and high blood were moderate-fat (31.8%), and moderate-CHO (⬃50%).
pressure may be reduced or completely eliminated by Caloric intake on all diets was limited to 1533 kcal/d.
following these plans. Overall weight loss was 8.6 ⫾ 0.4 kg (9.7%) with a reduc-

Table 17. Energy expenditure from 0 –5 years (The Lifestyle Heart Trial)
Experimental Control p*
Baseline
(B) 1 year 5 years Baseline 1 year 5 years B–1 year B–5 years
Times/week (F) 2.66 4.97† 4.34 2.38 2.87 3.57 0.06 0.64
Hours per week (D) 2.26 5.02‡ 3.56 2.42 2.52 2.90 0.12 0.50
Minutes/bout 51 60 30 61 53 49
F ⫻ D (minutes/week) 135 298 130 145 152 174
* All p values are two-tailed and each is the result of a test of the null hypothesis that the change between two particular visits (e.g. baseline
and 1 year) does not differ between the experimental and control groups (14). Adapted from Ornish et al. (14,156).
† p ⫽ 0.0008 for frequency, baseline to year one in the experimental group (156).
‡ p ⫽ 0.0004 for duration, baseline to year one in the experimental group (156).
tion in waist circumference of 8%. There were no signifi- (78%), and moderate in protein (15%) for 21 days. Partic-
cant differences in weight loss between diet groups, al- ipants were encouraged to eat to satiety. Average energy
though weight loss was least on the VLF as compared with intake decreased from 2594 to 1569 kcal/d and average
the moderate-fat diet. weight loss was 7.8 kg. Although interesting, this study is
Surwit et al. (153) conducted a 6-week weight-loss trial that not relevant outside Hawaii.
compared the efficacy of two hypoenergetic (1100 kcal/d), Other studies allowing ad libitum intake of VLF diets
VLF (⬍11%), high-CHO diets (71%) varying in sucrose con- were published by Barnard (using the Pritikin diet) and
tent. The high-sucrose diet contained 43% total energy from Ornish. In the Barnard articles (155,158 –166), the subjects
sucrose; the low-sucrose diet only 4%. Subjects in both groups were 3-week residents of the Pritikin Longevity Center who
lost comparable amounts of body weight and body fat. CHO engaged in medically supervised daily aerobic exercise,
source had no effect on weight loss as long as energy was primarily walking on a treadmill, and consumed the Pritikin
restricted. These data clearly show that high sucrose or com- high-complex CHO, high-fiber, low-fat, low-cholesterol,
plex CHO consumption does not cause obesity, hyperglycemia and low-salt diet. All meals and food were provided onsite.
or insulin resistance in the absence of dietary fat. Although it Barnard (155) reports 2643 males and 1897 females con-
is quite possible that sucrose or complex CHOs may produce suming VLF, high-fiber diets for 3 weeks lost 5.1 and 3.3
different effects when total energy intake is greater, the use of kg, respectively, representing a 5.5% and 4.4% decrease in
sucrose or other CHOs in a low-fat, weight-reduction program body weight (men and women, respectively.) Although
seems both safe and effective (providing a good refutation to BMI of patients is not provided, average weights of 91.9 kg
proponents of low-CHO diets). and 74.8 kg (men and women) indicate program participants
Heilbronn et al. (33) studied 35 obese patients with type 2 were overweight.
diabetes assigned to one of three 1600 kcal/d diets for 12 Another 3-week study (162) assessed the role of diet and
weeks. The diets were VLF (10%), high CHO (72%), or high- exercise in management of hyperinsulinemia. Seventy-two
monosaturated or high-saturated fat (32%), lower CHO (50%). patients were divided into three groups based on fasting
Diet composition did not affect the magnitude of weight loss, serum glucose and insulin measurements. Thirteen type 2
with subjects losing an average of 6.6 ⫾ 0.9 kg. diabetic and 29 insulin-resistant subjects had a BMI ⬎30.
Normal subjects (n ⫽ 30) had a BMI ⬃27. (Data collected
VLF diets before BMI levels were lowered for overweight.) An overall
Do VLF diets, when consumed ad libitum, decrease ca- body weight reduction of 4% was reported for all three
loric intake? The answer is a qualified yes because most groups.
studies of individuals consuming these types of diets were One drawback to the Barnard studies is the omission of
not designed to assess the effect of diet on weight loss, but information regarding actual caloric intake (or energy ex-
rather the effects of lifestyle change (e.g., low-fat diet, penditure). It can be assumed that participants ate low-
exercise, stress reduction) on disease risk or reversal. One calorie diets because these diets are very high in dietary
exception is the study of Shintani et al. (157) who fed 20 fiber (35 to 40 g per 1000 kcal), and The New Pritikin
obese native Hawaiians a pre-Western contact traditional Program (15) recommends a daily caloric intake of 1000 to
Hawaiian diet low in fat (7%), high in complex CHOs 1200 kcal/d. An analysis of 7 days of menus from The

Pritikin Principle (17)§ indicates an average intake of 1467 Two studies show that consumption of a low-fat (but
kcal/d. Amazingly, this is nearly identical to intakes re- not a VLF) diet results in increased caloric intake but
ported by Larosa et al. (57; 1461 kcal/d) for subjects con- decreased body weight (174,139). Raben et al. (174)
suming high-fat, low-CHO diets. reports that over a 12-week period, normal weight indi-
Ornish et al. (156) collected data on 28 patients who viduals consuming LFAL diets (25.6% fat) lost weight
followed The Lifestyle Heart Trial for 1 year (experi- (1.3 kg) despite decreased fat intake (37.4% to 25.6%)
mental group), and 20 patients who made more moderate but increased total caloric intake (3,059 to 3,203 kcal).
changes (control group). At 5 years (14), data were Dietary fiber was significantly increased as well. The
available from 20 experimental and 15 control patients authors were puzzled by these results, noting subjects did
(starting BMI 28.4 and 25.4, experimental vs. control, not change physical activity levels while under study.
respectively). All completed a 3-day diet diary at base- They attribute the “paradoxical” finding to an underesti-
line, and after 1 and 5 years. Although energy intake at mation of daily intake (based on 7-day food records)
baseline was slightly higher than 5 years later, these before the study (by 11%) and an overestimation of
changes were not significantly different between groups, energy content of the experimental diet¶.
or over time (Table 16). Intake of fat, both as percent The study by Prewitt et al. (139) was not designed to
calories, and absolute amount (g/d) significantly de- study weight loss but rather weight maintenance. Eigh-
creased in the experimental group from the baseline high teen subjects (12 with BMI 22.9 and 6 with BMI 38.4)
of 29.7% (63.7 g/d) to 6.22% (12.7 g/d) at 1 year, and were studied in an outpatient metabolic setting for 24
8.5% (17.3 g/d) at 5 years. The control group also de- weeks to determine the effects of diets with different
creased fat intake over time, from 30.5% (57.4 g/d) at compositions as part of a weight-maintenance regimen.
baseline, to 28.8% (52.4 g) at 1 year, and 25% (44.1 g/d) All subjects were fed a 37% (high-fat) control diet for 4
at 5 years. Fat intake was significantly different between weeks, the caloric intake estimated by energy require-
the two groups at 1 and 5 years. Patients in the experi- ments (basal energy expenditure ⫻ 1.4). For the next 20
mental group lost 10.9 kg (23.9 lb.) at 1 year, and weeks, they received a low-fat (20%), low-fiber diet
sustained a weight loss of 5.8 kg (12.8 lb.) at 5 years. (3g/d) containing ⬃1800 kcal. All meals were provided
Weight loss was significantly different from the control onsite. Throughout the study, energy adjustments were
group, whose body weight changed little from baseline. made as needed in an attempt to maintain body weight of
The Ornish Multicenter Lifestyle Demonstration Project subjects within ⫾1 kg of initial weight at study entry. If
(167) was conducted in 333 patients (194 experimental, a subject’s weight varied beyond ⫾1 kg over 3 days, she
139 control) at eight sites throughout the United States. was switched to a higher calorie level until weight re-
Data from this project show that mean weight signifi- turned within 1 kg of initial weight. Over the course of
cantly decreased in the experimental group from baseline the 20-week low-fat diet, despite adjustments in energy
to 3 months (4.2 kg), 1 year (4.7 kg), 2 years (4.9 kg), and to maintain body weight, subjects lost body weight
3 years (3.3 kg). However, dietary intake data and BMI (2.8%) and body fat (11.3%)储. Prewitt concludes, “a
was not provided. higher energy intake was needed to maintain body weight
That weight loss resulted from decreased fat intake is on a low-fat than a high-fat diet,” especially in subjects
not controversial (42,43,121). One would expect that a with a BMI of ⬎30.
46.33 to 51 g/d (417 to 459 kcal) fat decrease would How can these disparate results be explained? In exam-
result in weight loss. What is curious is that the signifi- ining possible reasons for weight loss in the face of in-
cant reduction in fat intake did not apparently result in a creased energy (and decreased fat) intake, changes in phys-
significant reduction in total caloric intake, and yet sub- ical activity, metabolic rate, and thermic effect of food are
jects still lost weight. Can subjects consume less fat, the considered. Prewitt et al. (139) examined each of these
same number of calories, and still lose weight? If so, factors and concluded that because physical activity had not
these data would disagree with all studies (but two) changed, most, but not all, of the observed energy intake
which show that as dietary fat decreases so does caloric
intake in both normal weight (168 –173) and overweight
¶ An 11% increase in caloric intake at the beginning of the study would mean subjects
subjects (20,39,40,134,137,138,140 –142,145,157 [see consumed 3395 kcal before and 3203 after reduction in fat. These data would then make
references 27,42,43,117 for reviews of the effect of di- sense, and support the contention that ad libitum intake of a low-fat, high-fiber diet results
etary fat intake and weight change]). in decreased caloric intake.
储 The largest single increases in caloric intake occurred when subjects went from consuming
the high-fat diet to the low-fat diet (7% increase, 132 kcal) and during the last 4 weeks of
the study. By the end of the 20-week low-fat diet period, individuals with a BMI ⬎30
§ It is interesting to note that The Pritikin Principle is based on caloric density, not reduction consumed 28% more energy (534 kcal), and those with BMI ⬍30 consumed 14% more
of fat. However, when one regularly consumes foods low in caloric density, a low-fat, energy (259 kcal) as compared with their consumption during the 4-week high-fat diet
low-calorie diet results. period.

was accounted for by increased metabolic rate and increased

thermogenesis. Dietary adherence may have also been a Evidence Statement: Weight loss on VLF diets
problem. may be the result of lifestyle modification, which may
In The Lifestyle Heart Trial (14,156), weight loss from include decreased fat and energy intake, increased
baseline to 1 year could be due to changes in physical energy expenditure, or both. Evidence Category B.
activity. Data indicate that frequency (F) (times per week)
and duration (D) (h/wk) doubled in the experimental group
(from 135 min/wk to 298 min/wk) from baseline to year 1 Body Composition
(Table 17). Intensity was not reported in this study. The The Ornish Multicenter Lifestyle Demonstration Project
increase in frequency and duration, however, could account (167) reported a significant decrease in body fat from 25.7%
for almost all the first-year weight loss**. Interestingly, at baseline to 21.3% at 1 year and 22.4% after 2 years. Body
from 1 to 5 years, exercise duration and frequency de- fat of 23.4% at 3 years was not significantly different from
creased in the experimental group (although there was no baseline.
significant difference between groups, or over time). Even 2. Nutritional Analysis
with a possible (and probable††) increase in exercise inten-
sity, the decrease in duration and frequency, coupled with ● What is the nutritional profile of low-fat and VLF diets?
the same energy intake is not enough to prevent some ● Do diets provide adequate levels of nutrients, based on
weight regain, which is exactly what happened between current dietary recommendations?
years one and five‡‡. It is unclear from the data if weight Nutritional analysis of a VLF diet (13, pp. 107–111)
gain from year 1 to 5 was significant in the experimental indicates that VLF diets provide adequate levels of all
group because analysis was conducted to determine differ- nutrients except vitamin E, B12, and zinc (Table 9). This
ences between groups over time. Furthermore, that the 1-day analysis seems slightly high in sodium, probably the
experimental group was overweight, and the control group result of added seasoning (teriyaki sauce). Ornish et al.
normal weight may confound the analysis. The data show (156) report the diet to be nutritionally adequate for all
that the normal weight controls maintained a consistent nutrients except vitamin B12, as expected, which was sup-
level of physical activity (1 hour, 3 times per week, e.g., 20 plemented. Scherwitz and Kesten (176) conducted the Ger-
min/d), and energy intake (1652 kcal/d) over the 5 years, man Lifestyle Change Pilot Program (GLCPP) to gain ex-
resulting in maintenance of a stable weight. This occurred in perience applying the program to a culture other than the
the context of a diet that contained ⬍30% fat. United States. Nutritional analysis of lifestyle and control
In addition to physical activity, other factors to consider groups show the nutritional content of the low-fat vegetar-
include changes in metabolic rate, the thermic effect of a ian diet was very nutrient dense, containing more vitamin
high-CHO diet (although this could not account for a sig- and mineral content for the same caloric value than the
nificant portion of the weight loss) (54), and possible inac- control group’s more typical German diet. However, the
curacies of the diet diaries. Food intake was assessed using treatment group’s intake of vitamins E, B12, D and zinc fell
3-day diaries, collected at baseline, year 1 and year 5. It is below the Recommended Daily Allowance because of the
likely that subjects consumed fewer than the reported 1800 omission of animal food products. Addition of animal
kcal/d from baseline to year 1, and greater than 1800 kcal/d protein (e.g., Pritikin) and education to consume more di-
from years 1 to 5§§. Finally, the sample size at 5 years verse foods that are high in these nutrients would be bene-
(experimental n ⫽ 20; control n ⫽ 15) may not have been ficial and eliminate the need for supplementation¶¶. Com-
large enough to detect differences (175). puter analyses of menus used at the Pritikin Longevity
Center show that the therapeutic plan is nutritionally
adequate (161).
** For example, Joe Hartman is 5 feet, 8 inches tall and weighs 184 pounds (BMI 28).
Walking 2.3 mph (26 min/mile), 298 min/wk burns 4.3 kcal/min or 1281 kcal/wk, translating
into a potential weight loss of 19 pounds per year (1281 kcal ⫻ 52 weeks/3500 kcal).
†† Exercise capacity significantly increased from 9.59 METS at baseline to 11.15 after 3
Evidence Statement: VLF diets are low in vita-
months, 11.66 after 1 year, to 10.88 after 2 years, and to 11.03 after 3 years in the mins E, B12, and zinc. Evidence Category B.
Multicenter Trial (167).
‡‡ After 1 year, and an ⬃19-pound weight loss, Joe increases exercise intensity to 3.2 mph
(18:45 min/mile), and burns 5.2 kcal/min. However, because F ⫻ D has decreased to 130
min/wk, total weekly energy expenditure is now only 676 kcal/wk, half as much as before
VLF, very high-CHO diets, high in fruits, vegetables, grains,
and weight is regained. beans, and soy contain thousands of protective phytochemi-
§§ This is supported by a) nutritional analysis of diets presented in Eat More, Weight Less, cals, e.g., isoflavones, carotenoids, bioflavonoids, retinols, ly-
and Dr. Ornish’s Program for Reversing Heart Disease, which indicate average 3-day
caloric intake of 1315 kcal/d, not 1800, b) Ornish (148), which indicates an intake of 1400
kcal/d, and c) the question of compliance to an 1800-kcal diet containing 50 to 60 g of fiber
per day. ¶¶ See Appendix for Ornish’s recommendations regarding supplements (www.web.md).

copene, and genistein that have anti-aging, anti-cancer, and dramatic reduction in total and LDL cholesterol is noted.
anti-heart disease properties. However, some VLF diets, based For example, use of drug alone reduces cholesterol by 20%;
on poor food choices, may mean lower than recommended addition of lifestyle intervention achieves an additional 19%
levels of certain nutrients such as iron, phosphorus, calcium, reduction (165). In one study, patients were contacted 2 to
and zinc. Fiber intake may also be low (154). This means that 3 years after leaving the center. Blood samples obtained
specific food choices within the context of a VLF diet are from 52 (75%) patients revealed significant increases in
critical. Data on the impact of a relatively high proportion of cholesterol. However, the follow-up values were signifi-
low-fat and fat-free alternatives to traditional foods in a free- cantly lower than the entry values (159). Similar results
living population in the absence of intensive dietary counseling were reported at 5-year follow-up (158).
are not yet available (29). In addition, qualitative changes in LDL show that particle
Nutritional questions on the use of VLF diets include size was increased, and LDL oxidation was decreased im-
uncertainty about compromised absorption of fat-soluble plying a reduction in risk for atherosclerosis and its clinical
vitamins, and the impact of increased dietary fiber on the sequelae (177).
absorption of minerals. Twenty patients who had complied Schaefer et al. (38) reported consumption of a low-fat diet
with the Pritikin diet longer than 4 years showed no signs of under weight maintenance conditions significantly lowered
nutritional inadequacy in more than 50 blood tests, includ- plasma TC, LDL and HDL-cholesterol (mean change,
ing those for iron status, trace minerals, and vitamins (161). ⫺12.5%, ⫺17.1%, and ⫺22.8%, respectively), but that this
3. Metabolic and Adverse Effects diet significantly increased plasma TG levels (47.3%) and
the TC/HDL ratio (14.6%). In contrast, consumption of an
● Do very low-fat diets affect blood lipids, blood pres- LFAL diet accompanied by significant weight loss (⫺3.63
sure, and blood insulin levels? kg) resulted in a mean decrease in LDL cholesterol
● Are adverse effects associated with these diets, or are (⫺24.3%), and mean TG levels and TC/HDL ratios not
there subgroups that should not use them? significantly different from values obtained at baseline.
They concluded that an LFAL diet when combined with
Blood Lipids weight loss is better than a low-fat diet without weight loss
Diets that lower serum TC, specifically LDL-cholesterol with respect to blood lipid levels.
levels, are believed to lower the risk of coronary heart In the study by Kasim-Karakas et al. (151), subjects re-
disease. In studies that lasted from 21 days to 1 year, ceived a controlled euenergetic diet in which dietary fat was
reducing fat content to ⬍10% of energy reduces total and reduced stepwise from 35% to 25% to 15% over 4 months.
LDL cholesterol levels in both men and women Thereafter, they followed an ad libitum 15% fat diet for 8
(14,28,33,154 –156,158,162–165,180). Some changes were months. Two months after subjects switched to the LFAL
sustained for 2 to 3 years (14,159), and up to 5 years (158). diets, TG levels decreased. Levels remained stable for the rest
Intensive diet and lifestyle modification provided additive of the 12 months and were not different from baseline values.
benefit to that of cholesterol-lowering medication (165). During the ad libitum period, TC levels remained low. An
The Ornish Multicenter Project (167) reported significant unexpected finding was the increase in LDL cholesterol to
changes in total and LDL cholesterol were sustained for 3 baseline levels within 2 months of switching to the ad libitum
years (despite the program lasting for 1 year). Total choles- diet (levels had previously decreased in response to decreased
terol decreased from 202 mg/dL to 183.7 mg/dL, and LDL fat intake), although LDL levels remained stable for the rest of
decreased from 122.9 mg/dL to 101.7 mg/dL (baseline to the study. HDL levels decreased as dietary fat decreased, and
year 3). It is not known what affect, if any, the intervention remained the same during the LFAL condition.
had on use of lipid-lowering drugs, which were used by Blood lipid changes occurring in individuals following
54% of experimental group patients. In the Lifestyle Heart VLF diets may be attributed to weight loss (6), decreased
Trial, data collected from subjects 4 years post-treatment intake of fat and saturated fat, and/or high fiber intake,
indicate total and LDL cholesterol were higher than at 1 rather than increased CHO content, per se (28,29).
year but lower than at baseline. These changes were relative However, low-fat, high-CHO diets often lower not
to the reduction in fat intake (greatest at 1 year vs. 5 years). only LDL cholesterol but also HDL cholesterol (28,33,153–
In this study, no significant difference between groups, or 155,162,164,165). Although lower HDL levels usually in-
over time, was reported for total and LDL cholesterol at five crease risk of coronary heart disease (178) there are no data
years (167). showing that physiological reduction of HDL cholesterol
Men and women (premenopausal and postmenopausal) levels with a low-fat diet is detrimental. In countries where
who participate in the 3-week Pritikin Longevity Center VLF diets are the norm, and TC and HDL cholesterol are
residential program consistently show decreased total and both very low, the incidence of heart disease is much lower
LDL cholesterol levels (166). When an aggressive diet and than in the United States (179). In the Lifestyle Heart Trial,
exercise program is added to cholesterol-lowering drugs, a however, no change in HDL was reported at 1 or 5 years

(14). In the Multicenter Project, HDL initially decreased during an ad libitum diet period, although rate of weight loss
from baseline to 3 months, but then showed a significant was unaffected by insulin levels.
increase by 2 and 3 years (e.g., 36.7 mg/dL vs. 42.2 mg/dL, Surwit et al. (153) reports that high sucrose or complex
baseline vs. 3 years) (167). CHO intake does not cause hyperglycemia or insulin resistance
Although TG levels are reported to increase in response in the absence of dietary fat, and when calories are restricted.
to short-term consumption of VLF diets (20), the type of The confusion in this area is probably due to the fact that
CHO consumed may play a role in determining the meta- hyperinsulinemia results from a high sucrose intake in the
bolic response. For example, diets containing 70% CHO do presence of high fat (e.g., typical American diet). VLF diets
not lead to hypertriglyceridemia as long as leguminous, that are also high in fiber decrease blood insulin levels and
high-fiber foods are consumed (30). In addition, TG levels improve insulin sensitivity (182) as does physical activity.
may be reduced by weight loss (6). These factors may be the Thus, the decreased blood glucose and/or insulin levels re-
reason why TG levels decreased (28,154,155,158,162), or ported for VLF diets may be a consequence of caloric restric-
did not change (180,156). Some attribute adverse metabolic tion, weight loss, dietary fiber, and/or physical activity, rather
effects of high-CHO diets to their sucrose content (181). than diet composition. In the context of a low-calorie diet,
However, Surwit (154) reported reduction in TG levels even consuming a very-low CHO (e.g., Atkins) or VLF diet (e.g.,
after overweight women were fed a high-sucrose but re- Pritikin) results in decreased fasting insulin levels.
duced calorie diet (1553 kcal/d) for 12 weeks, indicating Kasim-Karakas et al. (151) reported lower plasma glucose
that high-sucrose is not a problem in the presence of a concentrations during the 10th and 12th months of the LFAL
low-fat, low-calorie diet. diet compared with other times. Insulin and hemoglobin A1c
concentrations did not change significantly during the study.
Plasma free fatty acid concentrations decreased significantly at
Evidence Statement: Low-fat and very-fat diets only one time point, during the 25% fat phase of the controlled
reduce LDL-cholesterol, and may also decrease euenergetic diet.
plasma TG levels, depending on diet composition. Agus et al. (152) compared the effect of high-glycemic
Evidence Category B. index (67% CHO, 15% protein, 18% fat) with the effect of
low-glycemic index (43% CHO, 27% protein, 30% fat) ener-
gy-restricted diets. Although weight loss was similar between
Blood Pressure the two groups, plasma insulin and serum leptin levels de-
Blood pressure decreased in most subjects consuming creased to a greater extent with the low-glycemic index diet.
VLF diets (28,154,160,162–164). These diets alone, or in Havel (34) reported that during weight maintenance, re-
combination with exercise, resulted in reduction or elimi- ducing fat content from ⬃30% to ⬃15% of the energy
nation of antihypertensive medication in some patients content of the diet did not affect fasting plasma leptin or
(160). Benefits may be attributed to dietary changes, phys- insulin concentrations; however, only fasting insulin and
ical activity, or weight loss (6). leptin concentrations were examined in this study. After the
Blood pressure did not change in individuals following weight maintenance phase of the study, the subjects were
The Lifestyle Heart Trial, because individuals already were followed during a 6-month period during which they con-
being treated appropriately. Effect of lifestyle change on sumed a 15% fat ad libitum high-CHO diet. In women who
medication use was not addressed. lost less than 7% of body mass, fasting plasma leptin and
insulin levels were unchanged, despite a modest but signif-
Blood Glucose, Insulin, and Leptin Levels icant average weight loss and more than 10 months on a
The very high-CHO content of VLF diets has led to VLF diet. However, women with a weight loss greater than
concern about possible effects on blood glucose and insulin 7% had larger reductions of percent body fat, and both
levels. Unfortunately, no study of VLF diets in the absence fasting plasma leptin and insulin levels decreased by ⬃35%.
of caloric restriction exists, so that any effect on blood The decreases of fasting insulin are likely to represent an
glucose and insulin could be attributed to energy restriction improvement of insulin sensitivity due to weight loss and
and weight loss rather than diet composition (33). the decreases of leptin are mostly due to decreases of body
Nevertheless, very low-fat, high complex CHO, high-fiber, fat. However, they are also likely to be partially due to the
energy-restricted diets usually result in decreased blood glu- decreases of insulin during the fasting period because the
cose and insulin levels (28,33,154,158,162–164). In some pa- decreases of insulin and leptin were shown to be correlated
tients with type 2 diabetes these types of diets combined with independently of the changes of body fat (34)储储.
daily exercise and weight control may result in discontinuation
of insulin usage (160). However, Grey and Kipnis (31) re-
储储 Because insulin is secreted rapidly during and in the period immediately after the
ported basal plasma insulin levels on a hypocaloric, high-CHO consumption of meals, and because circulating leptin exhibits a diurnal pattern that is
formula diet did not differ significantly from those observed dependent and proportional to insulin responses to meals, relying on fasting levels of insulin

Adverse Effects provided normal weight male subjects ad libitum access to

Few adverse effects of low-fat and VLF diets have been one of three covertly manipulated diets: low-fat (20% en-
reported. Barnard et al. (162) noted an initial increase in ergy as fat, 67% as CHO), medium-fat (40% energy as fat,
flatus, which generally subsides. No other adverse meta- 47% as CHO) or high-fat (60% energy as fat, 27% as CHO).
bolic or behavioral effects were reported. They reported that energy intake increased with percent fat,
Results of studies seem impressive but questions about and that lower fat, lower-energy diets were more satiating
long-term efficacy and risk reduction remain. Extrapolation than higher fat, higher energy diets.
to the general population from motivated individuals (e.g., When dietary fat content is drastically reduced, the
those with coronary heart disease) is questionable. The weight of the food consumed is maintained or slightly
independent effects of weight loss, physical activity and increased (38,188). Thus, exposure to high-CHO foods can
accompanying lifestyle interventions complicate interpreta- give rise to a marked restraining effect on the expression of
tion (29). The American Heart Association’s Science Ad- appetite, the potency and time course varying with the
visory recommends persons with insulin-dependent diabetes amount consumed and chemical structure (e.g., simple vs.
mellitus, elevated TG levels, and CHO malabsorption ill- complex CHO) (183).
nesses avoid VLF diets (29). Low-fat diets (15% to 20% fat) received higher hedonic
ratings compared with higher-fat diets (30% to 35% or 45%
4. Hunger and Appetite: Compliance to 50% fat (150). Hunger was not a problem in subjects
consuming low-fat diets. In fact, Schaefer et al. (38) re-
● What is the effect of low-fat and VLF diet on hunger
ported that during the low-fat, weight maintenance phase,
and appetite?
subjects frequently complained about the quantity of food
● What data supports compliance to low-fat and VLF and of abdominal fullness, making it difficult for them to
diets? consume all the food provided. The authors speculate that
complaints occurred because the low-fat diet weighed more
Low-Fat Diets than the baseline diet. When subjects were allowed to
The issue of satiety following ingestion of various ma- choose their own foods during the LFAL phase, they ate less
cronutrients (e.g., CHO, fat, and protein) has been the than what was provided during the low-fat weight-mainte-
subject of much research and is briefly reviewed here (see nance phase and lost weight. Decreases of leptin are related
also references 183–187). to increases of hunger in women during a prolonged, mod-
Studies of early satiety (occurring within 30 minutes after erately energy restricted diet (120). It is therefore possible
a preload) found protein having the greatest effect, followed that maintaining the diurnal pattern of leptin production
by CHO, and then fat (186,187). However, these studies did (induced by the insulin responses to dietary CHO) may
not adequately control for the differences in palatability or contribute to effects of ad libitum, moderately low-fat,
energy density of test foods (187). Short-term studies (2 and high-CHO diets to lower energy intake by preventing hun-
12 weeks) investigating the effect of covert manipulation of ger from increasing during weight loss.
the fat content of foods on total energy intake were con- Schlundt et al. (145) reported that compliance to di-
ducted in normal weight women. Those consuming lower etary advice to reduce fat or calories was best during the
fat diets (15% to 20%, or 20% to 25% fat) vs. higher fat first 6 weeks of a 15-week study. A follow-up of 71% of
diets (30% to 35%, or 35% to 40% fat) consumed fewer subjects who completed the study, obtained 9 to 12
calories and lost more weight (149,188). Stubbs et al. (184) months later, showed average total weight losses of 2.6
kg in the low-fat group, and 5.5 kg in the low-calorie
and leptin to assess overall central nervous system exposure to changes of insulin and leptin
group. Of these subjects, 14% showed no weight regain
is inadequate. Consumption of moderately fat restricted (⬃20%) meals results in increased from the end of the treatment to follow-up, 20% regained
postprandial insulin secretion and higher leptin levels over a 24-hour period compared with 1 kg or less, and 40% regained less than 3 kg. Results did
a day during which the same subjects consumed relatively high-fat (60%), low-carbohydrate
(20%) meals (36). Therefore, it is necessary to examine the time-course of insulin responses not differ as a function of the treatment group. Both
to meals and leptin concentrations over a prolonged period of time to assess the impact of groups experienced compliance problems related to eat-
dietary macronutrient content and composition on insulin secretion and leptin production
adequately. ing at social events, eating in the car, and emotional
Increased insulin secretion and leptin production may contribute to the effects of these eating (both negative and positive emotions). Despite
diets because both insulin and leptin act as long-term signals back to the brain to regulate
appetite, energy intake and energy expenditure. Regarding energy expenditure, during the
three treatment sessions devoted to handling social situ-
weight maintenance phase of the study discussed above, subjects needed to be fed 7% more ations and three devoted to overcoming emotional eating,
calories (⫹120 ⫾ 30 kcal/d) to maintain a stable body weight when they consumed 15% problems with these issues persisted. It is likely that
energy from fat compared with when they consumed 30% energy from fat. This suggests that
lowering dietary fat content also lowers regulated level of body adiposity, independent of high-risk situations that precipitate relapse are indepen-
energy intake. This change of the regulated level of body fat independent of energy intake dent of diet composition.
would have to be due to an increase of energy expenditure, an effect that could potentially
be mediated by increases of carbohydrate-induced postprandial insulin responses and 24-
Djuric et al. (150) designed an intervention trial to
hour leptin production (36). selectively decrease fat and/or energy intake in free-

Table 18. Dietary intakes of National Weight Control Registry enrollees by method of weight loss
Women (number) Men (number)
On own With assistance On own With assistance
Nutrient (128) (227) (46) (37)
Calories 1336 ⫾ 494 1289 ⫾ 443 1809 ⫾ 733 1531 ⫾ 478
Protein (%) 18.1 ⫾ 3.3 19.9 ⫾ 3.8 17.5 ⫾ 4.3 19.1 ⫾ 3.4
CHO (%) 55.9 ⫾ 10.7 55.2 ⫾ 8.4 55.5 ⫾ 8.8 57.1 ⫾ 8.1
Fat (%) 24.8 ⫾ 9.6 24.0 ⫾ 7.2 24.1 ⫾ 8.5 22.8 ⫾ 6.8
Adapted from Shick et al. (195).
Table 19. Characterization of diets used for weight loss and weight maintenance
Fat g CHO g Protein g
Type of diet Total kcals (%) (%) (%)
High-fat, low-CHO* 1450 97 (60) 36 (10) 108 (30)
Moderate-fat, balanced nutrient reduction 1450 40 (25) 218 (60) 54 (15)
Low- and very-low-fat 1450 16–24 (10–15) 235–271 (65–75) 54–72 (15–20)
Weight maintenance† 1491 40 (23.9) 208 (55.9) 72 (19.2)
* Based on average intake of subjects who self-selected low-CHO diets; studies lasting more than one week.
† Numbers determined by averaging data in Table 18.
living, premenopausal somewhat overweight women, to ventions indicate hunger was not a problem for subjects
examine the relative importance of these dietary factors following these diets. Using a seven-point analog scale that
on markers of cancer risk. Diets were nonintervention, ranked hunger vs. satiety, Noakes and Clifton (28) reported
low-fat (15%) maintenance of energy intake, low-energy subjects perceived hunger more before dinner, although
(25% reduction), or a combination of the two (low-fat caloric intake at this meal was not assessed. Using a five-
and low-energy). Meetings with a registered dietitian point analog scale, Surwit et al. (153) reported hunger
occurred at 2-week intervals for all diet groups. Daily decreased as diet duration increased (to 6 weeks), with all
records served as self-monitoring of intake and as a tool subjects reporting lower hunger levels at the end, rather than
for the dietitian to verify food intake. A total of 88 the beginning, of the study.
women completed the 12-week program. The 25 women Because energy density has been demonstrated to have
who dropped out did so within 6 weeks of their random- a robust and significant effect on both satiety and satia-
ization date, with similar dropout rates in all intervention tion independently of palatability and macronutrient con-
groups. Reasons for withdrawal included being too busy tent (187), the energy density of VLF diets must be
(n ⫽ 12), diet too hard to follow (n ⫽ 5), unhappy with considered when determining their effects on hunger and
diet assigned (n ⫽ 1), too stressed due to illness (n ⫽ 2), appetite. In addition to dietary fiber, water content of the
changed eligibility status (n ⫽ 2), and no longer inter- diet must be considered, as both fiber and water decrease
ested/unable to contact (n ⫽ 3). the caloric density of individual foods, and the overall
diet.
VLF Diets VLF diets are often high in fiber, providing 35 to 40 g
Studies of ad libitum VLF diets were generally short, dietary fiber per 1000 kcal (13,15–17). Burton-Freeman
ranging from 3 to 12 weeks (28,153,155,157). The Lifestyle (189) reports that women may be more sensitive to dietary
Heart Trial, originally a 1-year study (156), was extended to manipulation with fiber than men, and obese individuals, as
5 years (14). Limited data from short- and long-term inter- compared with lean, may be more likely to reduce food

intake with dietary fiber inclusion. Dietary fiber promotes Trials allowing ad libitum consumption of very low-fat (or
satiation and prolongs satiety, aids in long-term compliance even low-CHO diets) are equivocal in terms of efficacy due, in
to low-energy diets, and encourages healthy food choices part, to differences in adherence to the targeted macronutrient
and eating habits. Thus, the amount of fiber in the particular composition. The validity of dietary information given by trial
VLF diet is an important consideration when assessing participants is not always valid (190 –192). Obese subjects
compliance. typically under-report energy intake, especially fat intake (190)
At present there are no long-term clinical studies of the and overestimate physical activity (191).
effects of energy density independent of variations in fat Lyon et al. (192) assessed compliance to dietary advice
content. to decrease fat and increase CHO intake in eight moder-
ately overweight Swiss women during a 2-month period.
Compliance At supper, they were requested to eat a meal containing
13
C-glucose, and measure 13C by self-collection of ex-
Although short-term effects of these diets on hunger
pired air. Subjects were asked not to intentionally restrain
are promising, long-term effects are more important. Do
their total energy intake, but have their appetite drive
subjects continue to consume VLF diets long-term? Or-
their food consumption. At the end of the study, intake of
nish et al. (14) reported excellent adherence to all aspects
fat (g), protein (g), and total calories were significantly
of the program during the first year, and good adherence
after 5 years, as measured by percent diameter stenosis. reduced (fat: 92.5 to 52 g; protein 71 to 64 g; and
Percentage of daily energy intake from fat was main- calories: 1893 to 1518). Intake of CHO remained the
tained at less than 10%. The average person lost 24 same (182 g). When expressed as percent calories, fat
pounds in the first year and kept off more than half that intake significantly decreased (from 44% to 31%), and
weight 5 years later, even though they were eating more both CHOs and protein significantly increased (CHO:
food, and more frequently, than before without hunger or from 38% to 50% and protein from 15% to 17%). With
deprivation. It is important to note, however, that the this method, 54% of the variation in achieved weight loss
motivation of cardiac patients to reverse heart disease by was explained by differences in diet compliance (which
following a lifestyle intervention plan (which includes ranged from 20% to 93%; mean 60 ⫾ 8%)***. Patients
significantly reducing fat intake) may differ from that of with the greatest adherence lost the most weight. Those
obese patients whose motivation to lose weight may be who fail to lose weight on any diet are likely to be those
for reasons other than health. Thus, long-term compli- who do not adhere to the dietary composition no matter
what it is (186).
ance seen in the Ornish study does not necessarily trans-
late to obese individuals. 5. Performance and Physical Activity
Theusen et al. (147) studied Danish heart disease pa-
● What is the effect of VLF diets on physical perfor-
tients to assess how much dietary fat can be reduced for
mance?
long-term treatment to obtain an effective cholesterol-
lowering effect. For 3 months, 14 patients with severe Physical activity and exercise is strongly recommended
coronary heart disease were treated with a diet containing as part of the overall lifestyle plans recommended by both
10% of total energy from fat. Patients (and their wives) Pritikin and Ornish. Data support the use of CHO as fuel for
were instructed to eliminate intake of visible fats and exercising muscle (193). VLF diets have plenty of CHO
cholesterol-rich foodstuffs (e.g., egg yolk, liver, shell- (70% to 80%), supporting physical activity. No adverse
fish), limit meat to 50 mg/d, and keep sugar intake low. affects on performance have been reported in individuals
The consumption of rice, potatoes, vegetables and le- consuming VLF diets. Ornish et al. (14) report no signifi-
gumes was encouraged and up to five alcoholic drinks cant difference in exercise duration or frequency in individ-
per day were allowed. After 3 months, patients were uals following these diets for 5 years, however they do
asked to maintain a diet as low in fat as possible for report a significant increase in exercise intensity.
long-term treatment. Very few patients managed this diet
for longer than 3 months; only two had a fat intake of
Weight Maintenance
⬃10% after 1 year. However, half had a fat intake below
20%, and a 4-day diet recall showed a mean fat intake at Is There an Optimal Diet for Weight Maintenance?
the end of 12 months of 21.4% (range, 7.3% to 37.8%). In light of the current obesity crisis, prevention of weight
No explanations for increased fat (and energy intake) gain and weight maintenance is critical. Is there an optimal
were provided. It is also important to note that the mo- diet for accomplishing these goals?
tivation and adherence of a patient with existing heart
disease may be different from that of a patient who is
*** It is interesting to note the range of compliance to the advice to decrease fat intake, in
overweight, but has not yet been diagnosed with a this case, from 44% of total calories to 31%, an amount that is considered moderate, but not
chronic disease. low-fat.

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Appendix I: Descriptions of Popular Diets as much insulin as normal because it was ‘fooled’ by the
complementary meals into producing less insulin.” “Car-
1. Dr. Atkins’ New Diet Revolution by R. C. Atkins.
bohydrate addiction.”
New York: Avon Books, Inc., 1992.
4. Sugar Busters! by H. L. Steward, M. C. Bethea, S. S.
● Diet Summary: The four stages include 1) the Fortnight Andrews, and L. A. Balart. New York: Ballantine
Induction Diet; 2) the Ongoing Weight Loss Diet, 3) Books, 1995.
Premaintenance, and 4) Maintenance. The Induction Diet
● Diet Summary: Refined sugar and high-glycemic foods
limits carbohydrate to 20 g/d (1 cup permitted vegetables
and 1 cup salad vegetables). Unlimited amounts of beef, (e.g., potatoes, corn, white rice, white bread, carrots, and
turkey, fish, chicken, and eggs as well as fats are allowed. beer) are eliminated, resulting in weight loss, regardless
This phase of the diet allows no fruit, bread, grains, of whatever else you eat. Rationale: these foods cause a
starchy vegetables, or dairy products other than cheese, sugar spike and make you crave more high-glycemic
cream, or butter. Carbohydrate restriction is lessened dur- foods, leading to insulin resistance, which then makes
ing the other stages until individuals determine the level you overweight.
● Concerns: Protein intake and portion sizes not presented.
of carbohydrate they can consume while maintaining
their weight loss. For some, this could be as low as 25 g/d Normal protein requirement miscalculated. Intake of cal-
and for others it could be as high as 90 g/d. cium, iron, and vitamin E is low.
● Most Outrageous Statement: “Sugar is toxic!”
● Concerns: Calories not specified; diet nutritionally inad-
equate, providing lower than recommended intakes of 5. Eat More, Weigh Less by D. Ornish. New York:
vitamin E, vitamin A, thiamin, vitamin B6, folate, cal- Harper Paperbacks, 1993.
cium, magnesium, iron, zinc, potassium and dietary fiber. ● Program Summary: Dr. Ornish’s multifaceted approach
No calcium or potassium supplements, yet multiple other focuses on reversal of heart disease but is also recom-
supplements. Diet is high in saturated fat, cholesterol, and mended for weight loss. His program incorporates aspects
animal protein. of nutrition, exercise, stress management, and love and
● Most Outrageous Statement: “Most obese people gain intimacy. Moderate exercise (e.g., walking) is recom-
weight on fewer calories than nonobese.” mended. Stress management techniques include 1 hour
per day of stretching, breathing, meditation or prayer,
2. Protein Power! by M. R. Eades and M. D. Eades. progressive relaxation, and group support. Love and in-
New York: Bantam Books, 1996. timacy is accomplished through group support (one or
two times a week) designed to create a community in
● Diet Summary: Diet provides 0.75 g of protein per kilo-
which participants enhance intimate, nurturing relation-
gram IBW. Less than 30 g of carbohydrate per day
ships that further facilitate their adherence to the program.
allowed during the induction phase, up to 55 g/d there-
● Diet: VLF (10% fat) plant-based diet based on ad libitum
after. Calories based on protein requirements.
intake of fruits, vegetables, whole grains, beans, and soy
● Concerns: Low protein, low calcium intake.
products. It incorporates moderate quantities of egg
● Most Outrageous Statement: “Not a single adverse reaction.”
whites, and nonfat dairy or soy products and small
amounts of sugar and white flour.
3. Carbohydrate Addict’s Diet by R. F. Heller and ● The following daily supplements are recommended:
R. F. Heller. New York: Penguin Books, 1991.
● Vitamin C: 2 to 3 g.
● Diet Summary: Diet comprises two Complementary Meals ● Vitamin E: 100 to 400 IU.
(breakfast and lunch) and one Reward Meal (dinner). Com- ● Folate: 400 to 2000 ␮g.
plementary meals contain 3 to 4 ounces of meat, 2 cups of ● Women: flax seed oil: 2 g and fish oil: 2 g.
vegetables. Reward Meals start with salad, then 1/3 protein, ● Men: fish oil: 2 g.
1/3 low-carbohydrate vegetables, and 1/3 high carbohydrate, ● Selenium: 100 to 200 ␮g.
all consumed within 1 hour. No snacking allowed. ● Multivitamin: without iron for men and postmeno-
● Concerns: Low in calcium, iron, potassium and fiber; pausal women. Premenopausal women may benefit
high in fat and cholesterol. from a multivitamin with iron.
● Most Outrageous Statements: “When unlimited food is ● Concerns: Diet low in vitamins E, B12, and zinc. Ad-
consumed at the Reward Meal, the body doesn’t produce herence and palatability.
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Popular Diets: A Scientiﬁc Review

Article in Obesity Research · March 2001

Marjorie R Freedman Janet King

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Introduction selection of goal weights were appearance and physical

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Evidence-Based Guidelines ⬃1400 to 1500 kcal/d, regardless of macronutrient com-

Table 1. Grading system and evidence categories

RCT, randomized controlled trial.

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Table 3. Characterization of diets in absolute amount (grams)

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weight loss. They claim that “most overweight individuals

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ance, weight loss is a function of caloric intake, not diet

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Table 10. Reported metabolic effects of low-CHO, ketogenic diets

Blank cells indicate no published data; numbers refer to studies cited.

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N/A, Not available.

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N/A, Not available.

A. Underlying Philosophy, Claims, and Proposed

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Calories Fat CHO Protein

Calories Fat CHO Protein

Calories Fat CHO Protein

N/A, Not available.

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Table 14. Effect of moderate-fat diets on changes in body composition

N/A, Not available.

Calories vs. Fat

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N/A, Not available.

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was accounted for by increased metabolic rate and increased

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