International Journal of Obesity (2018), 1–6

© 2018 Macmillan Publishers Limited, part of Springer Nature. All rights reserved 0307-0565/18
www.nature.com/ijo

ORIGINAL ARTICLE
Effects of replacing diet beverages with water on weight loss
and weight maintenance: 18-month follow-up, randomized
clinical trial
A Madjd1,2, MA Taylor1, A Delavari3, R Malekzadeh3, IA Macdonald1 and HR Farshchi1,2

BACKGROUND: Beneficial effects of replacing diet beverages (DBs) with water on weight loss, during a 24-week hypoenergetic diet
were previously observed. However, it is not known whether this difference is sustained during a subsequent 12-month weight
maintenance period.
OBJECTIVE: To evaluate effects of replacing DBs with water on body weight maintenance over a 12-month period in participants
who undertook a 6-month weight loss plan.
DESIGN: Seventy-one obese and overweight adult women (body mass index (BMI): 27–40 kg m–2; age: 18–50 years) who usually
consumed DBs in their diet were randomly assigned to either substitute water for DBs (water group: 35) or continue drinking DBs
five times per week (DBs group: 36) after their lunch for the 6-month weight loss intervention and subsequent 12-month weight
maintenance program.
RESULTS: A total of 71 participants who were randomly assigned were included in the study by using an intention-to-treat analysis.
Greater additional weight loss (mean ± s.d.) in the water group was observed compared with the DBs group after the 12-month
follow-up period (−1.7 ± 2.8 vs − 0.1 ± 2.7 kg, P = 0.001). BMI decreased more in the water group than in the DBs group (−0.7 ± 1 vs
− 0.05 ± 1.1 kg m–2, P = 0.003). There was also a greater reduction in fasting insulin levels (−0.5 ± 1.4 vs − 0.02 ± 1.5 mmol l–1,
P = 0.023), better improvement in homeostasis model assessment of insulin resistance (−0.2 ± 0.4 vs − 0.1 ± 0.3, P = 0.013) and a
greater decrease in 2-h postprandial plasma glucose (−0.2 ± 0.3 vs − 0.1 ± 0.3 mmol l–1, Po 0.001) in the water group compared with
the DBs over the 12-month weight maintenance period.
CONCLUSIONS: Replacement of DBs with water after the main meal in women who were regular users of DBs may cause further
weight reduction during a 12-month weight maintenance program. It may also offer benefits in carbohydrate metabolism including
improvement of insulin resistance over the long-term weight maintenance period.
International Journal of Obesity advance online publication, 10 April 2018; doi:10.1038/ijo.2017.306

INTRODUCTION group, while they were on a cognitive behavioral therapy weight

Raised consumption of sugar sweetened beverages is commonly
associated with obesity,1,2 type 2 diabetes,3 and metabolic
syndrome and cardiometabolic risk factors.4 Replacement of
caloric sweeteners with low-energy sweeteners is of interest as a
dietary tool, as they offer sweet taste without the extra energy,5–7
and promote weight loss5 and adherence to the weight loss
program.8 However, it has been suggested that regular use of
intense sweeteners might lead to a paradoxical weight gain.9
There is a belief among nutritionists and health professionals that
increasing daily water consumption is a way to help weight loss,
but there are few data available to support this practice.
Previous interventional studies suggest water consumption in
subjects following a weight loss diet may lead to more weight loss
compared with the control.10,11On the other hand, a recent study
indicated that replacement of sugar sweetened beverages with
non-caloric alternatives, that is, either DBs or water, may have
similar effects on weight loss.12 Furthermore, in parallel with the
present study, it was recently claimed that obese people drinking
diet beverages (DBs) lost significantly more weight than the water
loss plan for 12 weeks,13 and also maintained significantly greater
weight losses over 1 year than subjects stopping DBs consump-
tion and drinking water only.14
In contrast, our recent study,15 which was the first phase of the
present longitudinal study, showed that replacement of DBs with
water may introduce a greater weight loss compared with DBs in
obese women on a weight loss program for 24 weeks. However, as
with all weight loss interventions, the long-term effectiveness of
such an approach is an issue, as someone who is prone to over
eating food may fail to maintain their changed behaviors in the
long-term and regain their weight.
So, the present study aimed to follow-up our participants in
order to investigate the changes in weight and anthropometric
measurements after the 12-month weight maintenance, as well as
the total of 18 months, consisting of the previously described
24 weeks active weight loss and a further 53 weeks weight
maintenance. The secondary objectives were to compare the
biochemical indicators of cardiometabolic risk during these
periods.

1
School of Life Sciences, Queen’s Medical Centre, University of Nottingham, Nottingham, UK; 2NovinDiet Clinic, Tehran, Iran and 3Digestive Disease Research Institute, Tehran
University of Medical Sciences, Tehran, Iran. Correspondence: Dr A Madjd or Dr HR Farshchi, School of Life Sciences, Queen's Medical Centre, University of Nottingham, Clifton
Boulevard, Nottingham NG7 2UH, UK.
E-mail: mbxsama@nottingham.ac.uk or hrfarshchi@gmail.com
Received 1 March 2017; revised 2 November 2017; accepted 22 November 2017; accepted article preview online 21 December 2017
 Weight loss of replacing diet beverages by water
A Madjd et al
2
MATERIALS AND METHODS
Participants
The participants were patients attending the NovinDiet Clinic, Tehran, Iran,
in order to lose weight. Eighty-nine healthy overweight and obese
participants were enrolled in the trial between March 2014 and June 2014.
Participants were women aged 18–50 years with body mass index (BMI) of
27–40 kg m–2. Of the 89 participants enrolled in the study, 18 withdrew
from the trial before the start and 71 participants were randomized and
began treatment and are included in the analysis (Figure 1).
All participants were self-reported habitual consumers of DBs who were
willing to introduce a dietary change to lose weight that might include
changing beverage consumption. They were required to be nonsmokers
and free of established cardiovascular diseases, stroke, diabetes, liver
diseases, kidney diseases, depression, cancer or autoimmune disease.
Participants included those who were able to keep an adequate 4-day food
record and show a readiness to change their eating and drinking behavior.
Exclusion criteria were pregnancy or lactation during the previous
6 months or planned pregnancy in the next 6 months, weight loss of 10%
of body weight within the 6 months before enrollment in the study,
participating in a research project involving weight loss or physical activity
in the previous 6 months, and taking medication to lower serum lipids
or that could affect metabolism or change body weight. Participants
reporting heart disorders, frequent chest pains, or faintness or dizziness on
the Physical Activity Readiness Questionnaire were excluded, while other
medical conditions required a physician’s approval to participate.
The study was approved by the ethical committee of The Digestive
Research Institute, Tehran University of Medical Science. All participants
provided written informed consent before study enrollment. This trial was
registered at www.irct.ir as IRCT201402177754N5.
Study design and interventions
The original weight loss study was a 24-week two-arm, single-blind,
randomized clinical trial (phase 1) comparing effects of replacing DBs with
water. It was decided before phase 1 was completed to continue for a
further 12-month follow-up weight maintenance program (phase 2). At the
start, eligible participants were randomly allocated after baseline measures
to the two groups. This was done using a computer-generated random
numbers method by the project coordinator, with distribution concealed
from the participants and dietitians until randomization was shown to the
study participants at the first intervention clinic appointment.
The study protocol included a preplanned data analysis with the
primary result of weight loss at 24 weeks (weight loss plan), which was

Individual evaluated for eligibility (n=89)

Visit 1: Medical History, Beck’s depression questionnaire, 4-day food

record, physical activity readiness questionnaire

Visit 2: fasting blood draw, 4-day food record collection

Excluded (n=18)
Beck’s depression result (n=3)
Randomized (n=71),
Type2 diabetes (n=7)
See Table 1 for baseline
Pregnancy (n=1)
characteristics
Diagnosed by renal failure (n=2)
Fill FD inadequately (n=5)

Hypo caloric diet+ drink diet

Hypo caloric diet+ drink water beverage after lunch (n=36)
after lunch (n=35)
“DBs Group”
“Water Group”

Water Group follow up (n=30) DBs Group follow up (n=32)

Dropped from intervention: Dropped from intervention:

Without any reason (n=1) Because of relocation (n=1)

Time constraint (n=1) Needs urgent surgery (n=1)

Dissatisfaction with program Scheduling conflict (n=1)

(n=1)

Analyzed (n=36)

Analyzed (n=35) ITT analysis (n=36)

ITT analysis (n=35) Completers (n=29)

Completers (n=27)

Figure 1. Screening, enrollment, randomization and follow-up of study participants.

International Journal of Obesity (2018), 1 – 6 © 2018 Macmillan Publishers Limited, part of Springer Nature.

published previously15 and after 77 weeks (53-week follow-up weight
maintenance plan).
In phase 1, the groups were the water group, in which participants
substituted habitual intake of DBs with a glass of water (250 ml) after the
main meal (lunch), and the DBs group, where participants were instructed
to drink DBs once a day (250 ml) after their main meal (lunch) five times a
week and then water only after the main meal (lunch) on the remaining
days of the week. Liquid intakes were matched among the two groups in
their main meal, but both groups were free to drink water as the beverage
during the rest of the days but were not allowed to consume DBs. This
protocol was continued for another 12-month weight maintenance period
(phase 2).
Furthermore, both groups were asked not to drink DBs or water during
the meal and also not add any low-calorie sweeteners such as aspartame
or sucralose to beverages such as tea or coffee. The participants in both
groups were given beverages at each treatment visit (in the diet and
lifestyle counseling visits).
Screening visit
At the screening visits, participants underwent a physical examination by a
general medicine physician, completed the Beck Depression Inventory16
and the Physical Activity Readiness Questionnaire.17 Potential participants
were instructed to keep a 4-day food record (details of the instruction were
described elsewhere).15
At this stage, three participants were excluded by Beck Depression
Inventory scores (49), and five participants were excluded because they
filled the food record with insufficient detail.
Interventions
Weight loss period (phase 1). For 24 weeks, the program was designed to
enable weight loss of 7–10% of starting body weight, at a rate of 0.5–1 kg
per week, according to the protocol of the NovinDiet clinic, which was
described elsewhere.15
In addition to the diet plan, principal behavior change strategies applied
included stages of change, goal setting, self-monitoring with food diaries,
waist measurements and physical activity.18,19 The goal was to gradually
increase activity levels to achieve 60 min of moderate activity 6 days per
week, which is the weight loss maintenance recommendation.20
During the weight loss program, at biweekly sessions, the participants’
reported problems with their weight loss program were discussed. The
details of the protocol of NovinDiet Clinic during weight loss program was
described previously.15
Weight loss maintenance period (phase 2). During the 53 weeks weight
maintenance program, participants attended a 60-min group session every
4 weeks, led by a registered dietitian to encourage energy restriction and
moderate-intensity physical activity. The participants were classified by
treatment group when attending the group session. At the same time, all
participants had regular individual visits every month for a general
nutrition consultation in order to establish how they could manage their
weight maintenance and were also weighed at these visits. Adherence to
the intervention was assessed by the dietitians, based on food, beverage
and physical activity logs, as well as checking their weight.
Both groups were provided with the same weight loss program and
the only difference was in terms of informing them about the type of
beverages they should consume.
Measurements
All anthropometric measurements of participants were conducted at
baseline, 24 and 77 weeks (except height, which was taken only at the
screening visit) by the dietitian.
Participants completed the food diary record at baseline, 24, 50 and
77 weeks to assess the energy and macronutrient intakes, which was
undertaken by using Nutritionist IV software (version 4.1; Hearst, First
Databank, San Bruno, CA, USA). Adherence to beverages treatment was
determined from daily beverage logs collected at each visit.
Blood samples of all participants were taken after overnight (8–10 h)
fasting, between 0700 and 0900 hours, at baseline, 24 and 77 weeks for
biochemical, cellular and hormonal measurements.
The details of the techniques used for anthropometric measures (weight,
waist circumference (WC), BMI) and blood sample analyses (fasting plasma
glucose (FPG) and 2-h postprandial (2hpp) glucose concentrations, fasting
serum insulin, insulin resistance evaluated by homeostasis model
© 2018 Macmillan Publishers Limited, part of Springer Nature.
Weight loss of replacing diet beverages by water
A Madjd et al
3
assessment of insulin resistance (HOMA-IR), glycated hemoglobin (HbA1c),
serum total cholesterol (TC), triglyceride, high-density lipoprotein (HDL)
and low-density lipoprotein (LDL)) have been described previously.15
Statistical methods
Baseline values of cardiovascular disease risk factors (including weight, WC,
LDL cholesterol, HDL cholesterol, TC, FPG, triglycerides, fasting insulin,
HOMA-IR, HbA1c and 2hpp glucose) and food intake data were compared
between the water and DBs groups by using unpaired t-tests.
At baseline, distribution was normal for all variables. All participants who
were randomly assigned and completed an initial assessment were
included in the final results by using an intention-to-treat analysis. Multiple
imputations with the use of linear regression were used to impute missing
values based on the assumption that data were missing at random. In the
primary analysis, we used analysis of covariance to compare the outcomes
between the two groups during the 53-week maintenance period
(phase 2) by adjustment on 24-week values as covariate.
In the secondary analysis, repeated-measures two-factor analysis of
variance with diet groups (water or DBs) and time (weeks 0, 24 and 77) as a
within-subject factor was used to assess the effects of the dietary
intervention by comparing changes in the dependent variables between
the groups over time. Where there was a significant main effect but no
interaction, post hoc comparisons were performed as appropriate with
Bonferroni’s adjustment for multiple comparisons to determine differences
between group means.
Statistical significance was set at P ≤ 0.05. All data are presented as
means ± s.d. unless otherwise indicated. Associations between variables
were assessed by simple correlational analyses (Pearson’s r). All statistical
analyses were performed by using SPSS 22.0 for Windows (SPSS Inc., IBM
Corp., Armonk, NY, USA).
The primary result addressed in this study was the difference in body
weight loss during the 18 months of study. With the assumption of a
detectable difference in weight loss of 2.5 kg between the two groups at
18 months and an s.d. of 3 kg, 51 participants were required to achieve
85% power of detecting a treatment effect (two-sided significance level of
5%). Allowing for a dropout rate of 25%, for an 18-month intervention, the
sample size required was 70.
RESULTS
Baseline characteristics
From 71 participants who began the study, 56 (or 79% of)
participants completed the 18-month trial (Figure 1). From week
24 to week 77, a total of six participants dropped out. Three
potential participants withdrew from the water group (one
without any reason, one because of time constraints and one
for dissatisfaction with the program). Also in the DBs group, three
participants withdrew (one because of relocation, one left because
need for urgent surgery and one because of a scheduling conflict).
At baseline, there were no statistically significant differences in
physical characteristics or biochemical measurements between
the intervention groups or between those who completed or did
not complete the study once recruited (Table 1).
Body weight, BMI and WC
As shown in Table 2, there was a significant difference in weight
reduction between the two groups after the 12-month weight
maintenance follow-up (P = 0.001). The weight change (means ± s.d.)
was − 1.7 ± 2.8 kg in the water group and − 0.1 ± 2.7 kg in DBs group.
Over the entire 18-month weight loss and weight maintenance
period, there was also a significant group × time interaction in
weight loss (P = 0.005).
The decline in BMI was greater in the water group than the
DBs group after 12 months (water: − 0.7 ± 1 kg m–2; DBs:
− 0.05 ± 1.1 kg m–2, P = 0.003). There was also a significant group ×
time interaction in BMI reduction over 18 months (P = 0.005).
In both groups, WC had decreased after the 12 months of
follow-up (water: − 2.1 ± 3.1 cm; DBs: − 1.2 ± 3.2 cm, P o0.001) with
no significant group × time interaction in WC effects between the
two groups after the 12 months of follow-up (P = 0.188).
International Journal of Obesity (2018), 1 – 6
 Weight loss of replacing diet beverages by water
A Madjd et al
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Lipid profiles Glucose metabolism measurement
Reductions in TC, LDL cholesterol and triglyceride concentration FPG, fasting serum insulin, HbA1C and HOMA-IR, and 2hpp
and an increase in HDL cholesterol were detected over the whole glucose, all decreased over the whole 18-month program in both
intervention period in each group (P o 0.001), but there were no groups (P o 0.001). Also between group, differences were
significant differences in these results between the two groups significant for all, except for HbA1C after the 12-month weight
during the 12-month weight maintenance intervention (Table 2). maintenance intervention (Table 2).
TC after 12 months had decreased by − 0.1 ± 0.1 mmol l–1 in the The mean reduction in FPG over the intervention was
water group vs − 0.04 ± 0.2 mmol l–1 in the DB group (P = 0.510). − 0.2 ± 0.3 mmol l–1 (water) and − 0.1 ± 0.2 mmol l–1 (DBs),
HDL cholesterol concentration after 12 months had increased (P = 0.018).
equally by 0.04 ± 0.1 mmol l–1 in both groups (P = 0.482). There was a significant difference in fasting serum insulin
LDL cholesterol had decreased similarly by − 0.1 ± 0.1 mmol l–1 concentration between the two groups after the 12 months of
(water) and − 0.1 ± 0.2 mmol l–1 (DBs) (P = 0.962). follow-up (−0.5 ± 1.4 mU l–1 in the water group vs
Triglyceride concentrations after 12 months had a trend of − 0.02 ± 1.4 mU l–1 in DBs, P = 0.02; Table 2).
reduction by − 0.1 ± 0.1 mmol l–1 (water) and − 0.04 ± 0.1 mmol l–1 HbA1c decline over the 12-month weight maintenance period
was similar in the water group (−0.2 ± 0.3%) and the DBs group
(DBs), (P = 0.052).
(−0.1 ± 0.2%, P = 0.07). However, there was a significant difference
between the groups in the changes over the whole 18 months
(P = 0.030).
In terms of 2hpp plasma glucose differences during the
Table 1. Subject characteristics before the interventiona 12 months weight maintenance period, the mean reduction was
Water group (n = 35) DBs group (n = 36) greater in the water group (−0.2 ± 0.3 mmol l–1) than the DBs
(−0.1 ± 0.3 mmol l–1, P o0.001). There was also a significant
Age, years 32.2 b
(6.9) 31.7 (6.8) group × time interaction in 2hpp glucose effects over the entire
Body weight, kg 88.2 (8.8) 87.6 (9.8) 18 months weight loss and weight maintenance period
BMI, kg m–2 33.9 (3) 33.5 (3.6) (P o 0.001).
WC, cm 104.6 (5.8) 103.5 (5.9) HOMA-IR decreased by − 0.5 ± 1.4 in the water group compared
TC, mmol l–1 4.8 (0.4) 4.7 (0.4) with − 0.02 ± 1.4 in the DBs group at the end of 12 months weight
HDL-C, mmol l–1 1.3 (0.2) 1.3 (0.2)
maintenance period (Table 2; P = 0.01). There was also a significant
LDL-C, mmol l–1 2.8 (0.4) 2.7 (0.5)
TG, mmol l–1 1.7 (0.2) 1.6 (0.2) group × time interaction in HOMA-IR reduction between groups
FPG, mmol l–1 5.2 (0.5) 5.3 (0.4) over the 18 months (P o0.001).
2hpp, mmol l–1 6.9 (0.7) 6.7 (0.8)
HA1C, % 5.1 (0.4) 5 (0.4) Food intake measurement
Insulin, mU l–1 13.7 (2.1) 13.1 (3.1)
HOMA-IR 3.2 (0.6) 3.1 (0.8) As reported at baseline, there was no significant difference in
energy intake. After 18 months, estimated energy intake
Abbreviations: BMI, body mass index; DBs, diet beverages; FPG, fasting measurements showed a significant reduction over time in both
plasma glucose; Hb A1C, glycated hemoglobin; 2hpp, 2-h postprandial; groups (P o0.001 for time effect). As presented in Table 3, there
HOMA-IR, homeostasis model assessment of insulin resistance; HDL-C,
was a significant group × time interaction for total energy intake
high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cho-
lesterol; TC, total cholesterol; TG, triglyceride; WC, waist circumference. over 18 months (P = 0.001).
a
Group difference, P40.05. There were no significant differences between Macronutrient intake measurements indicated no significant
groups at baseline . bMean (s.d.), (all such values). differences between the two groups at baseline. Nevertheless,
there was a greater carbohydrate deficit in the water group than

Table 2. Anthropometric and blood measurement characteristics in water and DBs groups from baseline to week 77a

Water group (n = 35) DBs group (n = 36) P-valueb P-valuec

Baseline Week 24 Week 77 Baseline Week 24 Week 77

Weight, kg 88.2 (8.8) 79.7 (7.9) 78 (6.1) 87.6 (9.8) 80 (9.7) 79.8 (8.2) 0.001 0.005
BMI, kg m–2 33.9 (3) 30.6 (2.7) 30 (2.3) 33.5 (3.6) 30.6 (3.5) 30.5 (2.9) 0.003 0.005
WC, cm d 104.6 (5.8) 96.4 (5.6) 94.3 (3.9) 103.5 (5.9) 95.8 (6.7) 94.5 (4.7) 0.188 0.286
TC, mmol l–1 d 4.8 (0.4) 4.4 (0.4) 4.3 (0.3) 4.7 (0.5) 4.2 (0.4) 4.1 (0.4) 0.51 0.548
HDL-C, mmol l–1 d 1.3 (0.2) 1.4 (0.2) 1.4 (0.2) 1.3 (0.2) 1.4 (0.2) 1.4 (0.1) 0.482 0.894
LDL-C, mmol l–1 d 2.8 (0.4) 2.3 (0.3) 2.2 (0.3) 2.7 (0.5) 2.2 (0.5) 2.1 (0.4) 0.962 0.787
TG, mmol l–1 d 1.7 (0.2) 1.4 (0.2) 1.3 (0.2) 1.6 (0.2) 1.3 (0.1) 1.3 (0.1) 0.052 0.273
FPG, mmol l–1 5.2 (0.5) 4.6 (0.5) 4.4 (0.4) 5.3 (0.4) 4.7 (0.4) 4.6 (0.3) 0.018 0.156
2hpp, mmol l–1 6.9 (0.7) 5.7 (0.5) 5.5 (0.4) 6.7 (0.8) 5.9 (0.6) 5.9 (0.4) o 0.001 o0.001
Hb A1C, % d 5.1 (0.4) 4.5 (0.5) 4.4 (0.4) 5 (0.4) 4.5 (0.4) 4.4 (0.4) 0.07 0.03
Insulin, mU l–1 13.7 (2.1) 10.7 (2) 10.2 (2) 13.1 (3.1) 11.4 (2.9) 11.4 (2.5) 0.002 o0.001
HOMA-IR 3.2 (0.6) 2.2 (0.5) 2 (0.5) 3.1 (0.8) 2.4 (0.7) 2.3 (0.6) 0.01 o0.001
Abbreviations: ANCOVA, analysis of covariance; ANOVA, analysis of variance; BMI, body mass index; DBs, diet beverages; FPG, fasting plasma glucose; Hb A1C,
glycated hemoglobin; HOMA-IR, homeostasis model assessment of insulin resistance; 2hpp, 2-h postprandial; HDL-C, high-density lipoprotein cholesterol; LDL-
C, low-density lipoprotein cholesterol; TC, total cholesterol; TG, triglyceride; WC, waist circumference. aData are presented as mean (s.d.) for the 71
participants . bP-values are for water relative to DBs group with the use of ANCOVA with 24 weeks values as covariate. cP values are for water relative to DBs
group (time × group interaction) by repeated-measures two-factor ANOVA. dSignificant main effect of time, Po 0.001.

International Journal of Obesity (2018), 1 – 6 © 2018 Macmillan Publishers Limited, part of Springer Nature.
 Weight loss of replacing diet beverages by water
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a
Table 3. Self-reported dietary intake in water and DBs groups during weight loss and weight maintenance (18-month follow-up)

Intake Water group (n = 35) DBs group (n = 36) P-valueb

Baseline Week 24 Week 50 Week 77 Baseline Week 24 Week 50 Week 77

Energy (kcal) 2461 (300) 1873 (192) 1826 (159) 1761 (125) 2429 (300) 1986 (355) 1960 (287) 1935 (224) 0.001
Protein (g) 89.3 (7.2) 79.7 (8.3) 82.2 (8.1) 81.2 (1.7) 87.2 (7.3) 76.4 (11.6) 76.5 (9.4) 77.2 (8.7) 0.748
Protein (%) 14.7% (2.1) 17.1% (1.6) 18.1% (1.6) 18.5% (1.7) 14.6% (2) 15.5% (1.6) 15.7% (1.2) 16% (1.1)
Fat (g) 97.4 (17.8) 67.4 (9.3) 65.9 (7.0) 62.9 (5.4) 94.3 (19.9) 68.5 (15.5) 67.3 (12.2) 66.1 (9.9) 0.133
Fat (%) 35.4% (3) 32.3% (2.3) 32.5% (1.8) 31.1% (1.7) 34.6% (4) 30.8% (2.2) 30.8% (1.7) 30.7% (1.6)
CHO (g) 306.9 (37.9) 237 (27.6) 226 (24.0) 217.6 (19.5) 307.9 (36.3) 266 (46.3) 262.2 (38.1) 257.7 (28.5) o0.001
CHO (%) 49.9% (1.7) 50.6% (2.5) 49.5% (2.4) 49.4% (2.3) 50.8% (2.7) 50.8% (2.7) 53.5% (1.5) 53.3% (1.7)
Fiber (g) 20.4 (5.5) 21.8 (5.5) 21.4 (4.7) 21.4 (4.1) 20.7 (3.1) 22.1 (3.1) 22.3 (2.8) 22.5 (2.7) 0.185
a b
Abbreviations: ANOVA, analysis of variance; CHO, carbohydrate; DBs, diet beverages. Data are presented as mean (s.d.) for the 71 participants . P values are
for water relative to DBs group (time × group interaction) by repeated-measures two-way ANOVA.

in the DBs group during the intervention (group × time interac-
tion, P o0.001, Table 3).
DISCUSSION
The present 18-month clinical trial indicates the beneficial effect of
replacing DBs with water, in female regular consumers of DBs who
were overweight or obese, while attending a 24 weeks voluntary
integrated weight reduction program,15 followed by a 53-week
weight maintenance program.
This study adds to the relatively sparse literature on the
question of effects of DBs vs water during weight loss and weight
maintenance. To our knowledge, the present 18-month rando-
mized clinical trial is the longest study to date comparing the
effects of DBs and water consumption after the lunch on weight
loss, weight maintenance and also indices of carbohydrate and
lipid metabolism during a weight control program.
The present trial provides evidence that drinking water may
lead to greater weight loss and improvement in insulin sensitivity
than drinking DBs. This is in contrast to recent studies, which
claimed no deleterious effects of DBs on weight loss,12 or even
a favorable impact of DBs in weight loss13 and weight
maintenance.14 However, the present results are consistent with
the study by Dennis et al.11, which showed the positive effects of
drinking pre-meal water on weight loss during a hypoenergetic
diet, even though our study involved post-meal drinking. In
addition, some observational studies reported positive associa-
tions between DBs, obesity and weight gain.21–23
The weight loss and weight maintenance of participants in our
integrated program was consistent with the targets that they were
set. In all, 5–10% weight losses have been reported in more
intensive clinic-based behavioral lifestyle modification plans,25–27
which are similar to the weight losses that we observed during the
first 6 months of our weight loss plan. This was expected as our
weight loss program contains energy restriction, activity monitor-
ing and frequent patient visits and consultation in the clinic.15
Successful weight loss interventions are those which produce
≥ 5% weight loss from baseline followed by a maintenance period
in which the weight loss is maintained until at least 12 months
from the start.24 The equivalent combination of energy and fat
restriction, regular physical activity and behavioral strategies
appears to be essential for successful weight maintenance.24
The analysis of the 12-month weight maintenance period (phase
2) indicates 1.6 kg more weight loss in the water group compared
with the DBs group. Considering the above definitions of
successful weight loss and maintenance plans, the results of the
whole 18-month weight loss and maintenance plans showed that
the participants in the water group lost 2.5 kg more weight than
participants in the DB group and thus a program involving water
drinking would appear to be more successful.
However, our results are contrary to the results of the Tate
et al.12 study, which showed no significant difference in weight
loss between water and DBs and another recent intervention
study reporting a greater weight loss with DBs compared with
water during 12 weeks, which was then maintained at the
9 month follow-up (total period 1 year).13,14 However, it should be
mentioned that these studies had a different design in terms of
not including any weight loss plan12 or had only cognitive
behavioral therapy for weight loss.13 Moreover, in these studies
the size of beverage and the time of drinking (for example,
consumption before the meal compared with during or after the
meal) were different. So, further studies are required to investigate
if any of those factors could influence the effects of replacement
of DBs with water on weight loss.
The beneficial effect of replacement of DBs with water on
weight loss in the present study may reflect better adherence to
the multidisciplinary weight loss plan in the water group leading
to a greater reduction in energy intake, which is consistent with
previous findings.7 The mechanism underlying the observed effect
on weight of DBs vs water is unknown.
The current study revealed major reductions in WC and
significant improvements in cardiometabolic risk characteristics
in both groups, which could be expected according to the degree
of weight loss during this time. However, there were no
differences between the two groups. By contrast, despite the
similar changes in fasting glucose concentrations in both groups,
fasting insulin sensitivity improved more in the water group than
the DBs group over the study.
The findings of this study may have clinical implications, which
indicate drinking only water could improve weight loss and
maintain it for the long term. It is in agreement with nutritionists
and popular weight loss programs, which recommend an increase
in water consumption for losing weight.25,26 In contrast, many
obese or overweight persons assume they can continue drinking
DBs when they wish to lose weight or maintain their weight loss
without any detrimental effects on their weight management.
Replacing DBs with water consumption also appeared to have a
beneficial impact on the improvement in insulin sensitivity during
weight loss and the subsequent weight maintenance period.
The main strength of this study was the fact that it was a
randomized, outpatient clinical trial with a comprehensive
management plan for an 18-month intervention. All participants
wished to lose weight and the middle-aged overweight and obese
women who participated were able to follow the weight
management plan and adhere to the weight management
protocol.27 Finally, providing the DBs for the DBs group and
water for the water group at each visit was an incentive for regular
visits to see the dietitian. This enabled compliance to be
reinforced in both study groups. On the other hand, the limitation
of this study is that only female adults who were overweight or

© 2018 Macmillan Publishers Limited, part of Springer Nature. International Journal of Obesity (2018), 1 – 6
 Weight loss of replacing diet beverages by water
A Madjd et al
6
obese and were regular DBs users were studied, rather than a
wider range of participants, such as people used to drink sugar
sweetened beverages, which may have different results. In
addition, finding the actual mechanisms behind the results seen
in the present study needs further research.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
ACKNOWLEDGEMENTS
We thank the staff of NovinDiet Clinic, Mansoureh Pahlevani, Zeynab Zolfaghari, Rahil
Ahmadi and Ziba Hooshmand, for their assistance in data collection and Dr Masoud
Solaymani and Dr Leila Janani, for their statistical consultation. Thanks also go to Dr
Asadi at Jaam e Jam Laboratory for the analysis of blood samples. We also thank
Abigail Barrett for her hypothesis that if people are in a protocol doing one healthy
thing, it could motivate to do more healthy options, which we have used in the
discussion. This study was supported by the School of Life Sciences, the University of
Nottingham, UK and the Digestive Disease Research Institute (DDRI), affiliated to
Tehran University of Medical Sciences (TUMS).
AUTHOR CONTRIBUTIONS
Experiments in this study were conducted in NovinDiet Clinic, Tehran. AM:
contributed to the initial study design, study protocol setup, data collection,
data analysis, and writing of the first draft of the manuscript. HRF: designed the
research, conducted the research, contribution to data interpretation, revision
of the manuscript and provided medical supervision. MAT, IAM: refined the
study design and contributed to data interpretation and redrafting of the
manuscript. RM and AD: provided advice and consultation for the study design,
conducted the research. All authors read and approved the final manuscript.
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