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A Low-Carbohydrate as Compared with a Low-Fat Diet in Severe Obesity
Open accessAbstract
BACKGROUND: The effects of a carbohydrate-restricted diet on weight loss and risk factors for atherosclerosis have been incompletely assessed. METHODS: We randomly assigned 132 severely obese subjects (including 77 blacks and 23 women) with a mean body-mass index of 43 and a high prevalence of diabetes (39 percent) or the metabolic syndrome (43 percent) to a carbohydrate-restricted (low-carbohydrate) diet or a calorie- and fat-restricted (low-fat) diet. RESULTS: Seventy-nine subjects completed the six-month study. An analysis including all subjects, with the last observation carried forward for those who dropped out, showed that subjects on the low-carbohydrate diet lost more weight than those on the low-fat diet (mean [+/-SD], -5.8+/-8.6 kg vs. -1.9+/-4.2 kg; P=0.002) and had greater decreases in triglyceride levels (mean, -20+/-43 percent vs. -4+/-31 percent; P=0.001), irrespective of the use or nonuse of hypoglycemic or lipid-lowering medications. Insulin sensitivity, measured only in subjects without diabetes, also improved more among subjects on the low-carbohydrate diet (6+/-9 percent vs. -3+/-8 percent, P=0.01). The amount of weight lost (P<0.001) and assignment to the low-carbohydrate diet (P=0.01) were independent predictors of improvement in triglyceride levels and insulin sensitivity. CONCLUSIONS: Severely obese subjects with a high prevalence of diabetes or the metabolic syndrome lost more weight during six months on a carbohydrate-restricted diet than on a calorie- and fat-restricted diet, with a relative improvement in insulin sensitivity and triglyceride levels, even after adjustment for the amount of weight lost. This finding should be interpreted with caution, given the small magnitude of overall and between-group differences in weight loss in these markedly obese subjects and the short duration of the study. Future studies evaluating long-term cardiovascular outcomes are needed before a carbohydrate-restricted diet can be endorsed.
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“We did not confirm previous findings that low-carbohydrate or high-protein diets caused increased weight loss at 6 months3–12 and that the advantage of these diets usually eroded by 12 months, with weight loss that was nearly or fully equivalent to that with low-fat diets6,11,18 or other diets.12”
From Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates (2009) · cites this paper as [7]
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“Nevertheless, low-carbohydrate, high-fat diets may lead to spontaneous reduction in calorie reduction and increased weight loss, especially over the short term50–52.”
From Maintenance of Lost Weight and Long-Term Management of Obesity (2018) · cites this paper as [52]
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“Several trials showed that low-carbohydrate, high-protein diets resulted in more weight loss over the course of 3 to 6 months than conventional high-carbohydrate, low-fat diets,4–12 but other studies did not show this effect.13–17”
From Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates (2009) · cites this paper as [7]
In the citing paper
“Significant reductions in fat mass including truncal fat, which is a marker for visceral obesity, have been demonstrated in many studies [9,11,26,29].”
From The case for low carbohydrate diets in diabetes management (2005) · cites this paper as [11]
In the citing paper
“It is interesting that despite advocating ad libitum fat and protein intake, a LoCHO diet may be hypocaloric either by design or by spontaneous reduction of intake [8-12].”
From The case for low carbohydrate diets in diabetes management (2005) · cites this paper as [11]
In the citing paper
“There are several other reports indicating metabolic advantage in low carbohydrate diets over short term (3–6 months) [8,10,11,26-28].”
From The case for low carbohydrate diets in diabetes management (2005) · cites this paper as [11]
In the citing paper
“Conversely, LoCHO diets have been consistently demonstrated to lower triglycerides and increase HDL [8-11,26-28].”
From The case for low carbohydrate diets in diabetes management (2005) · cites this paper as [11]
In the citing paper
“LoCHO diets have been reported to reduce fat mass including truncal fat over long term in many studies [11,21,26,29].”
From The case for low carbohydrate diets in diabetes management (2005) · cites this paper as [11]
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“In the landmark trials of low carbohydrate diets, the discontinuation and loss to follow-up rate was 40p”
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“Finally, as noted, the first head-to-head RCT comparisons of low versus normal-fat weight loss diets also suggest no benefits in terms of CVD risk factors of the lower fat diets.(7,8) The purported association between milk consumption and increased prostate cancer risk is countered by several facts.”
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“Many studies have shown that carbohydrate-restricted diets promote greater BM loss than conventional energy-restricted LFD(89,109,130,153,154).”
BackgroundImpact of low-carbohydrate diet on body composition: meta-analysis of randomized controlled studies
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“The majority of studies undertaken to date have been 6 months to 1 year in duration 47 with recent studies of up to 2 years.(1) 7 The high dropout rate in the present 6-month study did not prevent identification of significant LDL-C and body weight differences in the intent-to-treat analysis (using all available data).”
BackgroundResultLifestyle modification in the management of the metabolic syndrome: achievements and challenges
Marchesini, G. (2010) · Diabetes Metabolic Syndrome and Obesity · doi:10.2147/dmsott.s13860 · Cited by 151
“69–71 However, weight loss, metabolic outcomes, and dietary intake are no longer different after 36 months.”
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“Some studies have evaluated the relationship of macronutrient composition and lipids (13,14) with greater decrease in triglycerides on a low-carbohydrate diet but no change in other lipid parameters (13).”
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Diet, Insulin Resistance, and Obesity: Zoning in on Data for Atkins Dieters Living in South Beach
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BackgroundResultConsumption of sugars and body weight.
Van Baak, M. A., & Astrup, A. (2009) · Obesity Reviews · doi:10.1111/j.1467-789x.2008.00561.x · Cited by 103
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“Previous studies (25,26) have demonstrated more rapid weight loss with low-carbohydrate diets.”
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“More recently, high protein diets have been shown to be effective for reducing hepatic lipids, blood lipids, body fat, CVD risk and improve insulin sensitivity and anti-oxidative potential [132,145–149].”
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Dietary Treatment of Diabetes Mellitus in the Pre-Insulin Era (1914-1922)
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“The calories from alcohol were calculated as 7 kcal/g ( Poehlman and Horton 1999, p. 99 ).”
MethodGoss, A. M., Gower, B. A., Soleymani, T., Stewart, M., Pendergrass, M., Lockhart, M. E., Krantz, O., Dowla, S. A., Bush, N. C., Barry, V. G., et al. (2020) · Nutrition & Metabolism · doi:10.1186/s12986-020-00481-9 · Cited by 93
“Studies in nondiabetic participants with obesity using surrogate indices of insulin sensitivity have found that the VLCD resulted in significantly lower insulin resistance as measured by HOMA-IR [27–30] and improvement in insulin sensitivity using the QUICKI [31].”
MethodFibroblast growth factor 21 is a metabolic regulator that plays a role in the adaptation to ketosis
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“This may at least in part be due to two factors: the comparably higher weight loss by carbohydrate-restricted diets in these earlier studies [12, 13, 29, 30], and/or a more pronounced carbohydrate restriction in the low-carbohydrate diets used [ 12–14, 29, 31].”
Lu, M., Wan, Y., Yang, B., Huggins, C. E., & Li, D. (2018) · British Journal of Nutrition · doi:10.1017/s0007114517002902 · Cited by 91
“This traditional dogma is now contentious with several studies comparing low-fat with high-fat diet showing variable results on BW and cardiometabolic indicators in people with overweight or obesity (6 – 9) .”
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A review of the carbohydrate–insulin model of obesity
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“Reviews concluded that cultural adaptations [38], church-based studies [39], a low carbohydrate diet plan [40], individual sessions [38], family-centered programs [41, 42], and problem-solving skills [43, 44] promoted both weight loss and maintenance in minority adults.”
BackgroundDiet and Exercise for Weight Loss
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Diet and nutrition in polycystic ovary syndrome (PCOS): Pointers for nutritional management
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“More marked improvement in triglycerides (Samaha et al. 2003) and HDL-cholesterol (Foster et al.”
BackgroundInfluentialKuller, L. H., Kinzel, L. S., Gabriel, K. P., Kriska, A. M., Simkin‐Silverman, L. R., Conroy, M. B., Averbach, F. M., Pappert, W. S., & Johnson, B. D. (2006) · Journal of Women s Health · doi:10.1089/jwh.2006.15.962 · Cited by 88
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“In contrast to other studies that evaluated CRD [23-25], we had extremely low attrition and high compliance; thus, we are confident that the results reported represent the true biological adaptations to a CRD with and without supplemental soluble fiber.”
MethodResultAziz, A. A., Kenney, L., Goulet, B., & Abdel‐Aal, E. M. (2009) · Journal of Nutrition · doi:10.3945/jn.109.110650 · Cited by 88
Treatment of metabolic syndrome
Wagh, A., & Stone, N. J. (2004) · Expert Review of Cardiovascular Therapy · doi:10.1586/14779072.2.2.213 · Cited by 87
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“24 For instance, a decrease in triglycerides was observed on a low CHO diet.(23) Protein intake by itself induces insulin release; however, it is a much less potent secretagogue for insulin than is glucose in normal individuals.”
Background
Metadata
- Authors
- Samaha, F. F., Iqbal, N., Seshadri, P., Chicano, K. L., Daily, D. A., McGrory, J., Williams, T., Williams, M., Gracely, E. J., & Stern, L.
- Affiliations
- Veterans Health Administration (US)
- University of Pennsylvania (US)
- Drexel University (US)
- ORCID
- Gracely, Edward J.
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2003-05-22
- Volume
- 348
- Issue
- 21
- Pages
- 2074-2081
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W2154184102
- Semantic Scholar
- b42feb4332c5988f5d769f116b2b96ffdfc37bd4
- Cited by
- 1,267
- References
- 20
- Citations by year
- 2026: 9 · 2025: 17 · 2024: 26 · 2023: 24 · 2022: 39 · 2021: 38 · 2020: 58 · 2019: 33 · 2018: 36 · 2017: 36 · 2016: 43 · 2015: 28 · 2014: 37 · 2013: 46 · 2012: 62
- FWCI
- 70.68
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Physiology (medical) › Diet and metabolism studies
- Health Sciences › Medicine › Physiology (medical) › Dietary Effects on Health
- Health Sciences › Medicine › Surgery › Bariatric Surgery and Outcomes
- Keywords
- low-carbohydrate diet, low-fat diet, morbid obesity, weight loss, triglycerides, insulin sensitivity, diabetes mellitus, metabolic syndrome, atherosclerosis risk factors, dietary intervention
- MeSH terms
- Arteriosclerosis, Blood Glucose, Diabetes Mellitus, Diet, Reducing, Dietary Carbohydrates, Female, Humans, Insulin Resistance, Lipids, Male, Middle Aged, Obesity, Risk Factors, Triglycerides, Weight Loss, Body Mass Index, Diet, Fat-Restricted, Metabolic Syndrome
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