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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]
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
In the citing paper
“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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“The recent finding that the Atkins diet appears to cause greater weight loss, at least over 6 months (12,34,35), has given the now deceased Dr Atkins a new aura, a man ahead of his times.”
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“Various studies showed that, in the medium term at least, lowcarbohydrate, high-protein diets led to a greater weight loss than low-calorie, low-fat diets [10, 11], though other studies”
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“Previous stud ies have shown diets with reduced carbohydrates ( 1.5 g/kg) improve glycemic regulations in normal [11], obese [ 12 ,13] and diabetic [14-18] subjects.”
BackgroundInfluentialInfluence of a low-carbohydrate diet on endothelial microvesicles in overweight women
Wekesa, A., Doyle, L., Fitzmaurice, D., O’Donovan, Ó., Phelan, J. P., Ross, M., Cross, K. S., & Harrison, M. (2016) · Applied Physiology Nutrition and Metabolism · doi:10.1139/apnm-2015-0507 · Cited by 15
“LCD generally show greater weight loss at 6 mo when compared to low fat diets (Brehm et al., 2003; Foster et al., 2003; Gardner et al., 2007; Samaha et al., 2003; Yancy et al., 2004).”
BackgroundInterplay between proteins and metabolic syndrome–A review
Miglani, N., & Bains, K. (2015) · Critical Reviews in Food Science and Nutrition · doi:10.1080/10408398.2014.938259 · Cited by 17
“Both diets significantly decreased diastolic blood pressure and the insulin response to an oral glucose load (Samaha and Iqbal, 2003).”
BackgroundDietary approaches to overweight and obesity
McMillan-Price, J., & Brand-Miller, J. C. (2004) · Clinics in Dermatology · doi:10.1016/j.clindermatol.2004.01.003 · Cited by 15
A 6-Month, Office-Based, Low-Carbohydrate Diet Intervention in Obese Teens
Siegel, R., Rich, W., Joseph, E. C., Linhardt, J., Knight, J., Khoury, J. C., & Daniels, S. R. (2009) · Clinical Pediatrics · doi:10.1177/0009922809332585 · Cited by 15
“Fats 87 (6) 72 (6) 70 (6) 69 (6) 76 96 68 (7) Protein 84 (5) 83 ( 5 ) 82 (5) 71 (5) 72 (5) 73 (6) Height (cm)”
InfluentialAcute Insulin Secretion as a Predictor of Weight Gain in Healthy Humans
Silver, R., Mehta, S., Soeldner, J. S., Martin, B. C., Warram, J. H., & Goldfine, A. B. (2006) · Obesity · doi:10.1038/oby.2006.9 · Cited by 15
Effects of Low-Carbohydrate and Low-Fat Diets
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Clinical Use of a Carbohydrate-Restricted Diet to Treat the Dyslipidemia of the Metabolic Syndrome
Hickey, J. T., Hickey, L., Yancy, W. S., Hepburn, J., & Westman, E. C. (2003) · Metabolic Syndrome and Related Disorders · doi:10.1089/154041903322716705 · Cited by 14
Abdulle, A. E., Arends, S., van Goor, H., Brouwer, E., van Roon, A. M., Westra, J., Herrick, A. L., de Leeuw, K., & Mulder, D. J. (2020) · Scandinavian Journal of Rheumatology · doi:10.1080/03009742.2020.1780310 · Cited by 14
“A low-fat diet was defined as a diet in which < 30% of the total calories were derived from fat (11, 12), a low-carbohydrate diet was defined as a diet in which < 26% of the total calories were derived from carbohydrates (13), and low-calorie intake was defined as < 1000 kcal/day.”
BackgroundKlein, S., & Romijn, J. A. (2016) · Elsevier eBooks · doi:10.1016/b978-0-323-29738-7.00036-8 · Cited by 14
Adolescent obesity: etiology, office evaluation, and treatment.
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Dietary composition of carbohydrates contributes to the development of experimental type 2 diabetes
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“Recent studies have also indicated that in addition to improved insulin sensitivity, increased weight loss [16] and reduced biomarkers of cardiovascular disease risk [17] can be achieved by low carbohydrate diets.”
BackgroundLean, M. E. J., & Lara, J. (2004) · Nutrition Metabolism and Cardiovascular Diseases · doi:10.1016/s0939-4753(04)80011-5 · Cited by 14
Carbohydrates: how low can you go?
Steffen, L. M., & Nettleton, J. A. (2006) · The Lancet · doi:10.1016/s0140-6736(06)68357-8 · Cited by 14
Levine, M. J., Jones, J. M., & Lineback, D. R. (2006) · Journal of the American Dietetic Association · doi:10.1016/j.jada.2006.09.033 · Cited by 15
“Low-carbohydrate diets consistently decreased triglycerides (2,4, 5 ,7) and tended to increase HDL, and no studies showed an increase in LDL.”
BackgroundLow-carbohydrate diet disrupts the association between insulin resistance and weight gain
Leite, J. O. M., deOgburn, R. C., Ratliff, J. C., Su, R., Volek, J. S., McGrane, M. M., Dardik, A., & Fernández, M. L. (2009) · Metabolism · doi:10.1016/j.metabol.2009.04.004 · Cited by 14
Efecto de una dieta alta en grasas en el proceso de formación de cálculos biliares de colesterol
del Pozo, R., Mardones, L., Villagrán, M., Muñoz, K., Roa, S., Rozas, F., Ormazábal, V., & Muñoz-Roa, M. (2017) · Revista médica de Chile · doi:10.4067/s0034-98872017000901099 · Cited by 14
The mystery of the ketogenic diet: benevolent pseudo-diabetes
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“When consuming the same numbers of calories, KDs are more effective than standard calorie restrictive diets for body weight reduction and improvement of glycemic control in diabetic patients [24–28], and enable discontinuation or reduction of medications in some diabetic patients [18,27,29].”
BackgroundDiet variety based on macronutrient intake and its relationship with body mass index.
Lyles, T. E., Desmond, R. A., Faulk, L. E., Henson, S., Hubbert, K. A., Heimburger, D. C., & Ard, J. D. (2006) · PubMed Central · Cited by 14
Are long‐term FAD diets restricting micronutrient intake? A randomized controlled trial
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“The popularity of low-carbohydrate, high-protein diets for body weight management remains high, and meta-analyses seem to support their effectiveness for weight loss (Brehm, Seeley, Daniels, Seeley, Daniels, & D'Alessio, 2003; Hu et al., 2012; Samaha et al., 2003).”
BackgroundThe Effect of Ephedra and High Fat Dieting: A Cause for Concern!
Fleming, R. M. (2007) · Angiology · doi:10.1177/0003319706297965 · Cited by 14
Stone, N. J., & Schmeltz, L. R. (2007) · Expert Opinion on Pharmacotherapy · doi:10.1517/14656566.8.13.2059 · Cited by 14
“In addition, some studies of low carbohydrate diets in obesity demonstrated that insulin sensitivity and TG levels may improve more in severely obese patients who are on a low-carbohydrate diet [33] .”
BackgroundState of the science: behavioural treatment of obesity.
Jones, L. R., & Wadden, T. A. (2006) · PubMed · Cited by 14
Overweight and Obesity in the Context of Heart Failure
Evangelista, L. S., & Miller, P. S. (2006) · The Journal of Cardiovascular Nursing · doi:10.1097/00005082-200601000-00007 · Cited by 14
Can we advise our obese patients to follow the Atkins diet?
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“What possible mechanisms could be responsible for the apparent paradoxical effects of the Atkins diet? In actual fact, subjects consuming a low-carbohydrate high-protein diet appear to ingest roughly the same amount of calories as those on restricted calorie intake (5), and less than subjects on a similar ad libitum h…”
BackgroundMethodInfluentialGenetics of Obesity: Gene × Nutrient Interactions
Marti, & Martínez (2006) · International Journal for Vitamin and Nutrition Research · doi:10.1024/0300-9831.76.4.184 · Cited by 14
“In several weight-loss studies prescribing low carbohydrate diets (moderate to high fat content) as compared to low fat diets, there was no major difference in the average weight reduction [17].”
A low-fat diet improves fatigue in multiple sclerosis: Results from a randomized controlled trial
Chase, E., Chen, V., Martin, K., Lane, M., Wooliscroft, L., Adams, C., Rice, J., Silbermann, E., Hollen, C., Fryman, A., et al. (2023) · Multiple Sclerosis Journal · doi:10.1177/13524585231208330 · Cited by 13
Unlocking the potential: very-low-energy ketogenic therapy in obesity-related disorders
Simancas‐Racines, D., Reytor-González, C., Zambrano, A. K., Annunziata, G., Am, C., Verde, L., Frías-Toral, E., Guerra, C. V., & Hidalgo, R. (2025) · Food and Agricultural Immunology · doi:10.1080/09540105.2024.2442368 · Cited by 13
“In contrast, randomized clinical trials suggest that VLEKT has beneficial effects on the lipid profile (Brehm et al., 2003; Foster et al., 2003; Samaha et al., 2003; Yancy et al., 2004).”
InfluentialLlanos, A. A. M., Krok, J. L., Peng, J., Pennell, M. L., Olivo‐Marston, S., Vitolins, M. Z., DeGraffinreid, C. R., & Paskett, E. D. (2014) · SpringerPlus · doi:10.1186/2193-1801-3-175 · Cited by 15
Petrisko, M., Kloss, R., Bradley, P., Birrenkott, E., Spindler, A. A., Clayton, Z. S., & Kern, M. (2020) · Journal of Medicinal Food · doi:10.1089/jmf.2019.0266 · Cited by 14
“These results are similar to other studies that detected greater reductions in fasting insulin and improved insulin sensitivity with low-CHO diets compared with higher CHO diets.(4,15,38) Volek et al.”
ResultTargeting hepatocyte carbohydrate transport to mimic fasting and calorie restriction
Kading, J. C., Finck, B. N., & DeBosch, B. J. (2020) · FEBS Journal · doi:10.1111/febs.15482 · Cited by 13
Clinical Experience of a Diet Designed to Reduce Aging.
Rosedale, R., Westman, E. C., & Konhilas, J. P. (2009) · PubMed · Cited by 13
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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