Review article
Carbohydrate for weight and metabolic control: Where do we stand?
Kevin J. Acheson, Ph.D.*
Department of Nutrition and Health, Nestle´ Research Centre, Lausanne, Switzerland
Manuscript received June 30, 2009; accepted July 7, 2009.
Abstract
Changes in lifestyle are considered to play an important role in the etiology of obesity and type2 diabetes, and improvements in diet and physical activity are the first-choice treatment for these met-abolicdiseases. Sincethedietaryrecommendationsofalmost 40yagothatfatshouldbedecreasedandthat carbohydrate should be increased, recommendations for a healthy diet, except for minor amend-ments, have not changed that much. It is generally considered that caloric restriction is more important than changes in the macronutrient composition of the diet for weight loss and body weight control.Although this is true, there is increasing evidence that changes in the macronutrient composition of the diet (decreasing carbohydrate and increasing unsaturated fats and/or protein) play a role that facil-itates weight loss,increases insulin sensitivity andglucose tolerance,and improvescardiovascular riskfactors, such as blood pressure, blood lipid profile, and inflammatory markers, often independent of weight loss. Low-carbohydrate diets, whether they be high in unsaturated fats and/or protein, arenot recommended by the American Diabetes Association; however, despite this the Joslin DiabetesCenter currently advocates a diet composition of
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40% carbohydrate, 30% fat, and 30% proteinenergy for overweight and obese adults with type 2 diabetes or prediabetes or those at high risk of developing type 2 diabetes. Hopefully, future studies will indicate whether diets with a more equili-brated macronutrient composition than presently recommended are more appropriate for body weight and metabolic control.
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2010 Elsevier Inc. All rights reserved.
Keywords:
Obesity; Diet; Macronutrient composition; Weight reduction
Introduction
Lifestyle change in diet and physical activity is the best first-choice treatment for weight management [1]and,although the success rate over the long term is consideredpoor, it is still regarded as the primary strategy for weight loss in obesity and for improving metabolic control in type2 diabetics[2–6].Thirty years ago the Lausanne group provided evidencethat fat synthesis from dietary carbohydrate (de novo lipo-genesis) was a minor contributor to fat accumulation in obe-sity[7–10]and this was later confirmed by a series of isotopestudies measuring fractional hepatic de novo lipogenesis[11–14]. Such results were in line with, and supportive of,dietary guidelines at that time, which have remained rela-tively unchanged to the present day, namely that the propor-tion of carbohydrates in the diet should be relatively high,dietary fat should be restricted to 30%, and protein shouldbe in the 10–20% range of energy intake. However, despitethese recommendations, the prevalence of obesity and type2 diabetes has continued to increase. Although this has ledsome to question the recommendations, it is also very possi-ble that many individuals do not comply with the recommen-dations that have been made[15]. Nevertheless, one might expect that type 2 diabetics and others who have the meta-bolic consequences of an inappropriate diet would be morecompliant, unless they were willing to resort to pharmaco-logic therapy. Although the use of oral hypoglycemics andinsulin reduce hyperglycemia in the short and mediumterm, the fact that in some individuals it is possible to reduce,or completely discontinue, these medications by dietarychanges alone[16]should be sufficient evidence for greater effortstobemade toconvincethem tofollowthemost appro-priate diet to correct their metabolic symptoms. Unfortu-nately, where diet and weight control are concerned, thereis a mass of controversial literature available and theindividual who wishes to lose weight and/or correct meta-bolic symptoms often has to try several diets before finding,if at all, the one that works best for him or her.
*Correspondingauthor.Tel.:
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41-21-785-8919;fax:
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2010 Elsevier Inc. All rights reserved.doi:10.1016/j.nut.2009.07.002Nutrition 26 (2010) 141–145www.nutritionjrnl.com
Low-carbohydrate diets
Since the publication of a number of intervention trials in2003 that demonstrated certain advantages of consuminga low-carbohydrate diet [17–19], evidence is accumulatingthat will help define the most favorable macronutrient com-position of the diet for body weight and metabolic control.Although this evidence is not clearcut, it does appear to behaving some influence on the nutritional guidelines recom-mendedbyanumberofmedicalassociationsandinstitutions,which rely more and more on results from randomized,controlled clinical trials.In a meta-analysis of randomized control trials comparinglow-carbohydrate diets, without energy restriction against low-fat, energy-restricted diets, Nordmann et al.[20]con-cluded that low-carbohydrate diets were at least as effectiveas low-fat diets for weight loss, with the caveat that favorablechanges in triacylglycerols and high-density lipoprotein(HDL) cholesterol should be weighed against potentially un-favorable increases in low-density lipoprotein (LDL) choles-terol. However, the atherogenic potential of LDL cholesterolappears todependmore on particle size thanits concentration[21]. Although two studies that investigated the effect of three popular diets, the Atkins, Ornish, and Zone diets, onweight loss and metabolic risk factors over 1 y observed dis-parate results[22,23], with respect to weight loss on theAtkins diet the authors of both studies commented in favor of low-carbohydrate diets for weight loss[23]and improve-ment of cardiovascular risk factors[22,23]. Dansinger et al.[22]commented that their study was designed to investigatedietary adherence under uncontrolled conditions rather thanidentify the most appropriate diet for weight loss and reduc-tion of cardiovascular risk. Because the attrition rates werehigh (35% to 50%) and adherence to the diets decreasedover time, they concluded that sustained adherence toa diet, rather than diet type, predicted weight loss and reduc-tion of cardiac risk factors.Further support for low-carbohydrate diets was providedby the results of the OmniHeart trial[24], which demon-strated that the macronutrient composition of the diet, evenunder weight-maintenance conditions, could have significant effects on improving blood pressure and cardiovascular riskfactors. They observed that consuming a carbohydrate diet,similar to the Dietary Approaches to Stop Hypertension(DASH) diet, providing 15% protein, 58% carbohydrate,and 27% fat energy for 6 wk, resulted in decreased bloodpressure and lower total cholesterol, LDL cholesterol, andHDL cholesterol concentrations. Although HDL cholesteroldecreased, the decrease was much less than that of LDLcholesterol. However, two other weight-maintenance dietsconsumed over the same period and designed to replace10% of carbohydrate energy with protein (i.e., 25% protein,48% carbohydrate, and 27% fat) or unsaturated fat (15%protein, 48% carbohydrate, and 37% fat) lowered systolicand diastolic blood pressures further, improved blood lipidconcentrations, and further reduced estimated cardiovascular risk. The researchers discussed the potential of hypocaloricdiets rich in protein or monounsaturated fats to facilitateweight loss and the possibility that the DASH diet could beimproved by partial substitution of carbohydrate with pro-tein, from plant andanimalsources,or withmonounsaturatedfats. Indeed, under controlled hypocaloric conditions, thelow-fat, high-protein and high-monounsaturated fat, stan-dard-protein diets induced similar weight loss,
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10 kg, inoverweight and obese individuals over a 12-wk period,with concomitant improvements in insulin sensitivity andcardiovascular disease risk factors[25].Reaven[26]proposed substituting unsaturated for satu-rated fats to reduce LDL cholesterol concentrations and pro-vided evidence to support this by assigning insulin-resistant obese individuals to a 16-wk energy-restricted diet similar to that recommended by the American Diabetes Association(ADA) composed of 15% protein, 60% carbohydrate, and25% fat or another diet in which 20% of carbohydrate energywas substituted for by mono- and polyunsaturated fats suchthat the final composition was 15% protein, 40% carbohy-drate, and 45% fat [27]. Weight loss was slightly, but not sig-nificantly, greater on the 40% carbohydrate diet, which onemight expect if the subjects adhered to their energy-restricteddiet, and improved insulin sensitivity correlated with weight loss. Throughout the day insulin and triacylglycerol concen-trations were significantly lower, fasting triacylglycerol andE-selectin concentrations were lower, and greater increasesin HDL cholesterol concentrations and LDL particle sizewere observed after the lower-carbohydrate diet, indicatingthat,althoughweightlosswassimilaronthetwodiets,reduc-ing the carbohydrate content of the diet and replacing it withunsaturatedfatsimprovedcardiovasculardiseaseriskfactors.Other short-term studies have observed that an isocalorichigh-protein diet increases satiety[28]. In the same study,increasing the protein content of an ad libitum diet from15% to 30%, by replacing fat and keeping carbohydrate at 50% energy for 12 wk, decreased spontaneous energy intakewith concomitant reductions in body weight and body fat [28]. Increasing the protein content of a weight-maintenancediet, after a period of weight loss, was also found to improveweight maintenance when compared with a diet rich in carbo-hydratesovera12-wkperiod[29].Moreextremediets,suchastheverylowcarbohydrateketogenicdiet,evaluatedoverasim-ilartimeframe,havealsodemonstratedbetterbodyweightandfat losses, improved insulin sensitivity and glucose control,and decreased leptin concentrations in overweight and obesesubjects with atherogenic dyslipidemia when compared witha low-fat diet [30]. Although anti-inflammatory effects wereobserved on both diets, they were greater on the very low car-bohydrateketogenicdiet [31].Whensuchadietwasextendedto 6 mo and compared with a low glycemic index diet, it wasassociated with greater weight loss, better improvements inmetabolic control, and more frequent reduction or discontinu-ation of diabetes medication[16].
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Althoughthese short-termstudies have provided evidencethat dietary carbohydrate restriction has a number of healthbenefits, longer trials have shown mixed results[32,33].A comparison of three diets, low-carbohydrate unrestrictedenergy, Mediterranean restricted energy, and low-fat restrictedenergy,onweightlossinmoderatelyobesesubjectsover 2 y demonstrated significant decreases in body weight,blood pressure, and waist circumference with all diets; how-ever, these were greater on the low-carbohydrate and Medi-terranean diets than on the low-fat diet [33]. Concomitant improvements in lipid profiles and other markers were alsomore favorable on the low-carbohydrate and Mediterraneandiets[33]. In contrast, Sacks et al.[32], found that weight
loss of overweight subjects consuming reduced-calorie dietswith different fat, protein, and carbohydrate contents over 2 yoccurred regardless of the macronutrient composition of thediet. Unfortunately, despite intensive participant instructionthroughout this trial, adherence to the diets was poor andthe requisite differences between groups for energy intakeand macronutrient composition were not attained. Althoughthe shortcomings of this study were highlighted in an accom-panying editorial[34], it is probable that many readers willaccept the researchers’ conclusions without criticism.
Dietary guidelines
In the latest edition of Dietary Guidelines for Americans,2005,[1]it is emphasized that for body weight control, it isthe amount of calories consumed rather than the proportionsof protein, carbohydrate, and fat in the diet that is important,provided that the macronutrients are within the acceptablemacronutrient distribution range, recommended by the Insti-tute of Medicine (IOM)[35]. Although reference is made tothe DASH eating plan (21% protein, 57% carbohydrate, and22% fat energy) and the US Department of Agriculture foodguide (18% protein, 55% carbohydrate, and 29% fat energy,which includes a slight percentage discrepancy), the accept-able macronutrient distribution range for each macronutrient is considerable, 10–35% for protein, 45–65% for carbohy-drate, and 20–35% for fat [35], and can cover a wide varietyof different dietary paradigms. Although it is true that calorierestriction per se is important for weight loss[1], if calorierestriction can be achieved more easily by changing the mac-ronutrient composition of the diet and help an individualmaintain the required energy deficit by possible effects onmetabolism and/or reducing appetite[28,36,37], then themacronutrient composition of the diet is certainly an optionworth consideration. One important benefit of low-carbohy-drate diets is that only carbohydrate, not energy, intake isconsciously restricted. In reality energy intake decreasesspontaneously, due to the increasing proportion(s) of proteinand/or fat in the diet, which results in body weight loss asgood, if not better, than on conventional energy-restrictedweight-loss diets. Replacing carbohydrate by unlimited fat hasbeencriticizedforincreasingsaturatedfatandcholesterolintake; however, it has been proposed that high dietary fat isonly deleterious if there is sufficient carbohydrate in the diet to provide an hormonal state in which fat will be stored rather than oxidized[30,38]. Furthermore, the ‘‘high-fat diet’’ wasthe subject of a number of short-term studies (8 to24 d) in the1950s, reported in the
Lancet
Dr. Atkins DietRevolution
[40]in1972.It was clearly demonstrated that subjects consumed less fat on a ‘‘high-fat diet’’ than when they followed their habitualdiet, because it is virtually impossible to consume largeamounts of fat in the absence of carbohydrate, and it was pro-posed that the
high-fat diet
was a misnomer and that it shouldbe referred to as the
low-carbohydrate diet
[39].If carbohydrate is replaced by increasing protein, onemight expect that the satiating and thermogenic effects of protein[28,36,37,41]would encourage a negative energybalance and weight loss. However, potential deleterious ef-fects of long-term high-protein intakes on liver and kidneyfunctions have often been used as an argument against theuse of low-carbohydrate, high-protein diets.The 2005 Dietary Guidelines for Americans consider that proteins are consumed in sufficient amounts not to be a focusof the guidelines and because calorie restriction is believed tobe more important for weight control than the macronutrient composition of the diet, these topics are not discussed[1].The ADA recognizes the increasing number of studies pro-viding evidence in support of low-carbohydrate diets for weight control[42]and that diets with protein contentsgreater than 20% reduce glucose and insulin concentrations,reduceappetite,andincreasesatiety.Althoughtheacceptablemacronutrientdistributionrangeforproteinrecommendedbythe IOM is 10–35%[35], the ADA maintains that there is in-sufficient evidence to suggest that the usual protein intake of 15–20% should be modified because long-term effects onkidney function in diabetes are unknown and that the ADArequires more information on the long-term efficacy andsafety of low-carbohydrate, high-protein diets.DespitetheserecommendationsbytheADA,itisinterestingto note that the Joslin Clinical Nutrition Guidelines for over-weight and obese adults with type 2 diabetes or prediabetesorthoseathighriskfordevelopingtype2diabetesrecommendsadietwithamacronutrientcompositionof
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40%energyfromcarbohydrate, 30–35% fat, and 20–30% protein[43]and that their Why Wait program, albeit over 12 wk, provides a diet with an energy composition of 40% carbohydrate, 30% fat,and 30% protein[44]. Not only has the carbohydrate content ofthe dietbeenreduced,but ithas beenreplacedbyincreasingtheproteincomponentofthediet.Interestinglythistypeofdiet compositionissimilartothatofthePaleolithicdiet,consideredto be the most appropriate diet for our genome[45].
Paleolithic diet
Over the years Eaton and Eaton[46]ha ve made slight adjustmentstothemacronutrientcompositionofthePaleolithicdiet,butingeneralitcoversarangethatprovides19–35%pro-tein,22–40%carbohydrate,and28–58%fat [47].Eventhough
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