Low-carbohydrate diets and cardiometabolic health: the importance of carbohydrate quality over quantity

Sievenpiper, John L

doi:10.1093/nutrit/nuz082

Cited by 144Diet and metabolism studiesNutritional Studies and DietDiet, Metabolism, and Disease

Low-carbohydrate diets and cardiometabolic health: the importance of carbohydrate quality over quantity

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Sievenpiper, John L·2020·Nutrition Reviews

DOI 10.1093/nutrit/nuz082PMC PMC7390653

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Abstract

Carbohydrates are increasingly being implicated in the epidemics of obesity, diabetes, and their downstream cardiometabolic diseases. The “carbohydrate-insulin model” has been proposed to explain this role of carbohydrates. It posits that a high intake of carbohydrate induces endocrine deregulation marked by hyperinsulinemia, leading to energy partitioning with increased storage of energy in adipose tissue resulting in adaptive increases in food intake and decreases in energy expenditure. Whether all carbohydrate foods under real-world feeding conditions directly contribute to weight gain and its complications or whether this model can explain these clinical phenomena requires close inspection. The aim of this review is to assess the evidence for the role of carbohydrate quantity vs quality in cardiometabolic health. Although the clinical investigations of the “carbohydrate-insulin model” have shown the requisite decreases in insulin secretion and increases in fat oxidation, there has been a failure to achieve the expected fat loss under low-carbohydrate feeding. Systematic reviews with pairwise and network meta-analyses of the best available evidence have failed to show the superiority of low-carbohydrate diets on long-term clinical weight loss outcomes or that all sources of carbohydrate behave equally. High-carbohydrate diets that emphasize foods containing important nutrients and substances, including high-quality carbohydrate such as whole grains (especially oats and barley), pulses, or fruit; low glycemic index and load; or high fiber (especially viscous fiber sources) decrease intermediate cardiometabolic risk factors in randomized trials and are associated with weight loss and decreased incidence of diabetes, cardiovascular disease, and cardiovascular mortality in prospective cohort studies. The evidence for sugars as a marker of carbohydrate quality appears to be highly dependent on energy control (comparator) and food source (matrix), with sugar-sweetened beverages providing excess energy showing evidence of harm, and with high-quality carbohydrate food sources containing sugars such as fruit, 100% fruit juice, yogurt, and breakfast cereals showing evidence of benefit in energy-matched substitutions for refined starches (low-quality carbohydrate food sources). These data reflect the current shift in dietary guidance that allows for flexibility in the proportion of macronutrients (including carbohydrates) in the diet, with a focus on quality over quantity and dietary patterns over single nutrients.

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From Impact of Dietary Patterns on Metabolic Syndrome in Young Adults: A Cross-Sectional Study (2024) · cites this paper as [30]

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Sugar-sweetened beverage consumption and incident hypertension: a systematic review and meta-analysis of prospective cohorts
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Pretreatment Fasting Plasma Glucose and Insulin Modify Dietary Weight Loss Success: Results from 3 Randomized Clinical Trials
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The Effect of a Plant-Based Low-Carbohydrate (“Eco-Atkins”) Diet on Body Weight and Blood Lipid Concentrations in Hyperlipidemic Subjects
Jenkins, D. J. A., Wong, J. M. W., Kendall, C. W. C., Esfahani, A., Ng, V. W. Y., Leong, T. C. K., Faulkner, D. A., Vidgen, E., Greaves, K. A., Paul, G., et al. (2009) · Archives of Internal Medicine · doi:10.1001/archinternmed.2009.115 · Cited by 160 · see citing works
Low glycaemic index diets and blood lipids: a systematic review and meta-analysis of randomised controlled trials
Goff, L. M., Cowland, D. E., Hooper, L., & Frost, G. S. (2013) · Nutrition, Metabolism and Cardiovascular Diseases · doi:10.1016/j.numecd.2012.06.002 · Cited by 151 · see citing works
Increasing Adiposity: Consequence or Cause of Overeating?
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Effects of Berries Consumption on Cardiovascular Risk Factors: A Meta-analysis with Trial Sequential Analysis of Randomized Controlled Trials
Huang, H., Chen, G., Liao, D., Zhu, Y., & Xue, X. (2016) · Scientific Reports · doi:10.1038/srep23625 · Cited by 149 · see citing works
Dietary Glycemic Index, Glycemic Load, and Risk of Coronary Heart Disease, Stroke, and Stroke Mortality: A Systematic Review with Meta-Analysis
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Food sources of fructose-containing sugars and glycaemic control: systematic review and meta-analysis of controlled intervention studies
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Should Viscous Fiber Supplements Be Considered in Diabetes Control? Results From a Systematic Review and Meta-analysis of Randomized Controlled Trials
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A review of the carbohydrate–insulin model of obesity
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Carbohydrate quantity in the dietary management of type 2 diabetes: A systematic review and meta‐analysis
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“In systematic reviews and metaanalyses of randomized trials, the early improvements in glycemic control seen at 6 months were not found to be sustained at 12 months in people with diabetes.(22) Improvements seen in triglycerides and high-density lipoprotein cholesterol have also been shown to come at the expense of in…”
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Glycemic load, glycemic index and risk of cardiovascular diseases: Meta-analyses of prospective studies
Ma, X., Liu, J., & Song, Z. (2012) · Atherosclerosis · doi:10.1016/j.atherosclerosis.2012.05.028 · Cited by 110 · see citing works
A systematic review and meta-analysis of randomized controlled trials of the effect of konjac glucomannan, a viscous soluble fiber, on LDL cholesterol and the new lipid targets non-HDL cholesterol and apolipoprotein B ,
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Effect of a 6-month vegan low-carbohydrate (‘Eco-Atkins’) diet on cardiovascular risk factors and body weight in hyperlipidaemic adults: A randomised controlled trial
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‘Catalytic’ doses of fructose may benefit glycaemic control without harming cardiometabolic risk factors: a small meta-analysis of randomised controlled feeding trials
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Can pulses play a role in improving cardiometabolic health? Evidence from systematic reviews and meta‐analyses
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Dietary Pulses, Satiety and Food Intake: A Systematic Review and Meta-analysis of Acute Feeding Trials
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Shen, X. L., Zhao, T., Zhou, Y., Shi, X., Zou, Y., & Zhao, G. (2016) · Nutrients · doi:10.3390/nu8010039 · Cited by 100 · see citing works
Relation of Total Sugars, Sucrose, Fructose, and Added Sugars With the Risk of Cardiovascular Disease
Khan, T. A., Tayyiba, M., Agarwal, A., Mejia, S. B., de Souza, R. J., Wolever, T. M. S., Leiter, L. A., Kendall, C. W. C., Jenkins, D. J. A., & Sievenpiper, J. L. (2019) · Mayo Clinic Proceedings · doi:10.1016/j.mayocp.2019.05.034 · Cited by 93 · see citing works
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A systematic review and meta-analysis of randomized controlled trials of the effect of barley β-glucan on LDL-C, non-HDL-C and apoB for cardiovascular disease risk reductioni-iv
Ho, H. V. T., Sievenpiper, J. L., Zurbau, A., Mejía, S. B., Jovanovski, E., Au‐Yeung, F., Jenkins, A. L., & Vuksan, V. V. V. (2016) · European Journal of Clinical Nutrition · doi:10.1038/ejcn.2016.89 · Cited by 90 · see citing works
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Total Fructose Intake and Risk of Hypertension: A Systematic Review and Meta-Analysis of Prospective Cohorts
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Effects comparison between low glycemic index diets and high glycemic index diets on HbA1c and fructosamine for patients with diabetes: A systematic review and meta-analysis
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Relation of Vegetarian Dietary Patterns With Major Cardiovascular Outcomes: A Systematic Review and Meta-Analysis of Prospective Cohort Studies
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Coronary Heart Disease and Dietary Carbohydrate, Glycemic Index, and Glycemic Load: Dose-Response Meta-analyses of Prospective Cohort Studies
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Food and Dietary Pattern-Based Recommendations: An Emerging Approach to Clinical Practice Guidelines for Nutrition Therapy in Diabetes
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Effect of oat intake on glycaemic control and insulin sensitivity: a meta-analysis of randomised controlled trials
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The effect of liquid meal replacements on cardiometabolic risk factors in overweight/obese individuals with type 2 diabetes: A systematic review and meta-analysis of randomized controlled trials
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Evans, C. E. L., Greenwood, D. C., Threapleton, D. E., Gale, C. P., Cleghorn, C., & Burley, V. J. (2017) · American Journal of Clinical Nutrition · doi:10.3945/ajcn.116.143685 · Cited by 62 · see citing works
Macronutrient Intake–Associated FGF21 Genotype Modifies Effects of Weight-Loss Diets on 2-Year Changes of Central Adiposity and Body Composition: The POUNDS Lost Trial
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Effect of pasta in the context of low-glycaemic index dietary patterns on body weight and markers of adiposity: a systematic review and meta-analysis of randomised controlled trials in adults
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Chronic fructose substitution for glucose or sucrose in food or beverages has little effect on fasting blood glucose, insulin, or triglycerides: a systematic review and meta-analysis
Evans, R. A., Frese, M., Romero, J., Cunningham, J. H., & Mills, K. E. (2017) · American Journal of Clinical Nutrition · doi:10.3945/ajcn.116.145169 · Cited by 54 · see citing works
The Carbohydrate-Insulin Model of Obesity Is Difficult to Reconcile With Current Evidence
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Fructose vs. glucose and metabolism
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Pretreatment Fasting Glucose and Insulin as Determinants of Weight Loss on Diets Varying in Macronutrients and Dietary Fibers—The POUNDS LOST Study
Hjorth, M. F., Bray, G. A., Zohar, Y., Urban, L. E., Miketinas, D. C., Williamson, D. A., Ryan, D. H., Rood, J. C., Champagne, C. M., Sacks, F. M., et al. (2019) · Nutrients · doi:10.3390/nu11030586 · Cited by 40 · see citing works
Effect of the interaction between diet composition and the PPM1K genetic variant on insulin resistance and β cell function markers during weight loss: results from the Nutrient Gene Interactions in Human Obesity: implications for dietary guidelines (NUGENOB) randomized trial
Goñi, L., Qi, L., Cuervo, M., Milagro, F. I., Saris, W. H. M., Macdonald, I. A., Langin, D., Astrup, A. V., Arner, P., Oppert, J., et al. (2017) · American Journal of Clinical Nutrition · doi:10.3945/ajcn.117.156281 · Cited by 39 · see citing works
Fructose as a Driver of Diabetes: An Incomplete View of the Evidence
Sievenpiper, J. L., Tappy, L., & Brouns, F. J. P. H. (2015) · Mayo Clinic Proceedings · doi:10.1016/j.mayocp.2015.04.017 · Cited by 30 · see citing works
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Personalized nutrition: pretreatment glucose metabolism determines individual long-term weight loss responsiveness in individuals with obesity on low-carbohydrate versus low-fat diet
Hjorth, M. F., Astrup, A. V., Zohar, Y., Urban, L. E., Sayer, R. D., Patterson, B. W., Herring, S. J., Klein, S., Zemel, B. S., Foster, G. D., et al. (2018) · International Journal of Obesity · doi:10.1038/s41366-018-0298-4 · Cited by 29 · see citing works
Pretreatment Fasting Plasma Glucose Modifies Dietary Weight Loss Maintenance Success: Results from a Stratified RCT
Hjorth, M. F., Due, A., Larsen, T. M., & Astrup, A. (2017) · Obesity · doi:10.1002/oby.22004 · Cited by 28 · see citing works
Sickeningly Sweet: Does Sugar Cause Chronic Disease? No
Sievenpiper, J. L. (2016) · Canadian Journal of Diabetes · doi:10.1016/j.jcjd.2016.05.006 · Cited by 18 · see citing works
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Point: Glycemic Index—An Important but Oft Misunderstood Marker of Carbohydrate Quality
(606379), E. V., (19171693), S. K. N., (16628655), T. M. S. W., & (6454527), J. S. (2018) · Cereal Foods World · doi:10.1094/cfw-63-4-0158 · Cited by 15 · see citing works
Erratum: A systematic review and meta-analysis of randomized controlled trials of the effect of barley β-glucan on LDL-C, non-HDL-C and apoB for cardiovascular disease risk reductioni-iv
Ho, H. V. T., Sievenpiper, J. L., Zurbau, A., Mejía, S. B., Jovanovski, E., Au‐Yeung, F., Jenkins, A. L., & Vuksan, V. V. V. (2016) · European Journal of Clinical Nutrition · doi:10.1038/ejcn.2016.129 · Cited by 13 · see citing works
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Polycystic ovary syndrome
Stener-Victorin, E., Teede, H., Norman, R. J., Legro, R., Goodarzi, M. O., Dokras, A., Laven, J., Hoeger, K., & Piltonen, T. T. (2024) · Nature Reviews Disease Primers · doi:10.1038/s41572-024-00511-3 · Cited by 495 · see citing works
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Does a Ketogenic Diet Have a Place Within Diabetes Clinical Practice? Review of Current Evidence and Controversies
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Low-Carbohydrate Diet Macronutrient Quality and Weight Change
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Low‐carbohydrate diets, low‐fat diets, and mortality in middle‐aged and older people: A prospective cohort study
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Inverse J-Shaped Relationship of Dietary Carbohydrate Intake with Serum Klotho in NHANES 2007–2016
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Impact of Starch Gelatinization on Digestibility and Human Health
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The role of different nutrients in the prevention and treatment of cardiovascular diseases
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Longitudinal association of dietary carbohydrate quality with visceral fat deposition and other adiposity indicators
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Self-citation
Adaptive effects of dietary carbohydrate quality and quantity on insulin and glucose levels. A randomised controlled trial of people with obesity (CARBFUNC)
Revheim, I. (2018) · NORA - Norwegian Open Research Archives
Carbohydrate quantity and quality and cardio-metabolic risk
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Authors: Sievenpiper, J. L.
Affiliations: St. Michael's Hospital (CA)
Corresponding author: Sievenpiper, John L
ORCID: Sievenpiper, John L
Venue: Nutrition Reviews
Publisher: Oxford University Press (OUP)
Published: 2020-07-30
Volume: 78
Issue: Supplement_1
Pages: 69-77
ISSN: 0029-6643 (ISSN-L)
1753-4887
DOI: 10.1093/nutrit/nuz082
PMC: PMC7390653
OpenAlex: W3046587057
Cited by: 144
References: 111
Citations by year: 2026: 21 · 2025: 29 · 2024: 32 · 2023: 23 · 2022: 19 · 2021: 18 · 2020: 1 · 2019: 1
FWCI: 1.15
Type: journal article
Language: en
Open access: green
www.ncbi.nlm.nih.gov
Licence: academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model (vor)
Locations: Nutrition Reviews (publishedVersion)
PubMed Central (publishedVersion)
PubMed (publishedVersion)
Funders: PepsiCo, Nestlé, Wilmar, Amway, McDonald's, and Starbucks
Canadian Foundation for Innovation, Ontario Research Fund
Province of Ontario Ministry of Research and Innovation and Science
Canadian Institutes of Health Research
CIHR
Diabetes Canada, PSI Foundation, Banting & Best Diabetes Centre
American Society for Nutrition
Dried Fruit Council Foundation
National Dried Fruit Trade Association
Tate & Lyle Nutritional Research Fund
University of Toronto
Glycemic Control and Cardiovascular Disease in Type 2 Diabetes Fund
Nutrition Trialists Fund at the University of Toronto
Topics: Health Sciences › Medicine › Physiology › Diet and metabolism studies
Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Nutritional Studies and Diet
Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diet, Metabolism, and Disease
Keywords: low-carbohydrate diet, carbohydrate quality, cardiometabolic health, hyperinsulinemia, weight loss, dietary fiber, viscous fiber, whole grains, oat, barley, pulses, fruits, low glycemic index, sugar-sweetened beverages, diabetes mellitus, cardiovascular disease, obesity, energy expenditure, fat oxidation
MeSH terms: Cardiovascular Diseases, Diabetes Mellitus, Dietary Carbohydrates, Dietary Fiber, Humans, Insulin, Obesity, Glycemic Index, Diet, Carbohydrate-Restricted

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Low-carbohydrate diets and cardiometabolic health: the importance of carbohydrate quality over quantity

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