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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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“While this may limit the generalisability of these findings, this is comparable to other long-term dietary interventions [38,39].”
ResultDietary protein and risk of ischemic heart disease in middle-aged men.
Preis, S. R., Stampfer, M. J., Spiegelman, D., Willett, W. C., & Rimm, E. B. (2010) · The American Journal of Clinical Nutrition · doi:10.3945/ajcn.2010.29626 · Cited by 71
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O’Neill, B. J. (2020) · Current Opinion in Endocrinology Diabetes and Obesity · doi:10.1097/med.0000000000000569 · Cited by 72
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“Interestingly, there are a number of different weight loss diets that are high in animal and low in plant products such as the Atkins Nutritional Approach [61-63].”
BackgroundEffects of a carbohydrate-restricted diet on emerging plasma markers for cardiovascular disease
Wood, R. J., Volek, J. S., Davis, S. R., Dell'Ova, C. A., & Fernández, M. L. (2006) · Nutrition & Metabolism · doi:10.1186/1743-7075-3-19 · Cited by 76
“Consistent with other reports [20-22], simply instructing subjects to restrict carbohydrates resulted in a spontaneous reduction in energy intake (mean 718 kcal/day), suggesting that a CRD may be easier to adhere to than diet therapies that specifically target energy restriction.”
ResultDifferent dietary strategies for weight loss in obesity: role of energy and macronutrient content
Abete, I., Parra, M. D., Zulet, M. Á., & Martínez, J. A. (2006) · Nutrition Research Reviews · doi:10.1079/nrr2006112 · Cited by 75
“Energy intake restriction can also be related to the monotony or simplicity of the diet, because food carbohydrate choices are greatly limited by the requirements of minimising carbohydrates intake (Brehm et al. 2003; Samaha et al. 2003).”
Effects of increased dietary protein-to-carbohydrate ratios in women with polycystic ovary syndrome
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“These discrepancies regarding current dietary and exercise recommendations are unresolved, in part, because most previous studies have only examined the effects of diet or exercise alone (16, 35 , 41, 44), and thus there is a paucity of data comparing the efficacy of lifestyle modification programs consisting of diffe…”
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“Severely obese subjects with a high prevalence of diabetes and the metabolic syndrome lost more weight in a 6-month period on a carbohydrate-restricted diet than on a calorie- and fat-restricted diet (38).”
BackgroundPotential impact of carbohydrate and fat intake on pathological left ventricular hypertrophy
SHARMA, N., Okere, I. C., Duda, M. K., Chess, D. J., O’Shea, K. M., & Stanley, W. C. (2006) · Cardiovascular Research · doi:10.1016/j.cardiores.2006.11.007 · Cited by 69
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“Energy-restricted, HP diets have frequently been found to decrease triglycerides (4, 19, 20) and increase HDL cholesterol (4, 20) compared with energy-restricted, higher-carbohydrate diets.”
BackgroundLiver disease and malnutrition
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“The “standard” low fat high carbohydrate (LFHC) approach, long recommended because of its cardio-protective potential, has been repeatedly challenged during the past decade by proponents of Mediterranean type diets [3], high fat diets [4-6] and more recently high protein diets (e.”
BackgroundFechner, E., Smeets, E., Schrauwen, P., & Mensink, R. (2020) · Nutrients · doi:10.3390/nu12040991 · Cited by 64
“Sixteen studies were identified that compared a low CHO diet (<40–30 E%) to a MCD in different population groups: type 2 diabetes patients [33–36], patients with at least one characteristic of the metabolic syndrome [37] or one cardiac risk factor [38], overweight or obese participants [39–43] with or without type 2 d…”
Efficacy of Low-Carbohydrate Ketogenic Diet in the Treatment of Type 2 Diabetes
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“no limitation on the quantity of certain food groups, unlike energy-restricted diets that explicitly limit total daily calorie intake [10, 12, 14, 16].”
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BackgroundEffects of a high protein diet on body weight and comorbidities associated with obesity
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“A difference in weight loss was seen at 6 months but not 12 months which was very similar to the results of Samaha et al.(26,27).”
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Ceja-Galicia, Z. A., Cespedes-Acuña, C. L. A., & El-Hafidi, M. (2025) · International Journal of Molecular Sciences · doi:10.3390/ijms26020788 · Cited by 61
“Moreover, the reduction in carbohydrate uptake decreases blood pressure and triglyceride (TG) concentrations and increases high-density lipoprotein (HDL) levels in overweight individuals with MetS [2,3].”
Diet & insulin resistance: a review & Asian Indian perspective.
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Methionine and choline regulate the metabolic phenotype of a ketogenic diet
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“Human trials have shown that the weight loss achieved on low carbohydrate diets is equivalent to caloric restriction on a high carbohydrate diet and may also confer cardiovascular benefits [5–9].”
BackgroundChang, C. R., François, M. E., & Little, J. P. (2019) · American Journal of Clinical Nutrition · doi:10.1093/ajcn/nqy261 · Cited by 62
Michalczyk, M. M., Klonek, G., Maszczyk, A., & Zając, A. (2020) · Nutrients · doi:10.3390/nu12061854 · Cited by 62
“[49] in a randomised study with 126 severely obese subjects (BMI—43 kg/m2) in an experiment with a low-carbohydrate ketogenic diet (KD) and a hypocaloric low-fat diet (LFD) achieved significantly better results in serum glucose concentration in the LCKD group compared with the LFD group.”
BackgroundMethodResultInfluentialFatty acids linked to cardiovascular mortality are associated with risk factors
Ebbesson, S. O. E., Voruganti, V. S., Higgins, P. B., Fabsitz, R. R., Ebbesson, L. O. E., Laston, S., Harris, W. S., Kennish, J. M., Umans, B. D., Wang, H., et al. (2015) · International Journal of Circumpolar Health · doi:10.3402/ijch.v74.28055 · Cited by 60
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“On the other hand, there are several reports of differences in weight loss with high- and low-fat diets when energy intake is not fixed, suggesting that body weight is reduced slightly as dietary fat content of the diet is lowered.(25,26) However, no differences between low-carbohydrate and low-fat have been reported…”
Should snacks be recommended in obesity treatment? a 1-year randomized clinical trial
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“This is in line with anticipated weight loss differences used in power calculations in other studies (Heshka et al., 2003; Samaha et al., 2003; Brinkworth et al., 2004).”
ResultCOMPETING DIETARY CLAIMS FOR WEIGHT LOSS: Finding the Forest Through Truculent Trees
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“[17] studied 132 participants with severe obesity over 6 months and reported that those on a low-carbohydrate diet lost more weight than those on a calorie- and fat-restricted diet.”
BackgroundEffects of a Low-Fat versus a Low-Carbohydrate Diet on Adipocytokines in Obese Adults
de Luis, D. A., Aller, R., Izaola, O., Sagrado, M. G., Bellioo, D., & Conde, R. (2007) · Hormone Research in Paediatrics · doi:10.1159/000099329 · Cited by 58
“Several dietary approaches to this public health problem have been recommended. One approach is the Atkins Diet, a low-carbohydrate, high-fat diet that was first publicized by Dr. Atkins in 1972. Another approach is low-fat diets. Several outpatient studies [”
BackgroundDietary Proteins in Obesity and in Diabetes
Keller, U. B. (2011) · International Journal for Vitamin and Nutrition Research · doi:10.1024/0300-9831/a000059 · Cited by 63
Health Effects of Low-Carbohydrate Diets: Where Should New Research Go?
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“Of the published randomized trials (n = 9 studies) [3, 20–27] which evaluated the effects of low carbohydrate diets in diabetes management, only 3 trials were of 12 month duration or longer [24, 26, 27].”
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ResultNutritional Composition of the Green Leaves of Quinoa (Chenopodium quinoa Willd.)
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“Independent of weight loss, very low fat and high carbohydrate diets will not improve serum lipoproteins and, since long term compliance with such diets is very poor [25,75], they do not result in sustained loss of weight or body fat.”
BackgroundManagement of the Metabolic Syndrome
Hafidh, S. A. S., Senkottaiyan, N., Alpert, M., & Villarreal, D. (2005) · The American Journal of the Medical Sciences · doi:10.1097/00000441-200512000-00013 · Cited by 50
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“In this view, the recent successes attributed to low-carbohydrate, high-protein (Atkins-like) diets may simply reflect the thermogenesis and the greater satiety afforded by higher intakes of protein and not the ‘very low carbohydrate’ nature of the diets [59, 60 ].”
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“Several randomized trials have demonstrated an increase in HDL following a low-carbohydrate diet (Samaha et al., 2003; Yancy, Olsen, Guyton, Bakst, & Westman, 2004); however, the clinical significance of this increase is not clear.”
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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