REVIEW

CURRENT
OPINION Impact of carbohydrates on weight regain
Anja Bosy-Westphal a,b and Manfred J. Müller b

Purpose of review
Research on obesity treatment has shifted its focus from weight loss to weight-loss maintenance strategies.
The conventional approach of a low-fat diet is challenged by insights from glycemic effects of
carbohydrates on body weight regulation.
Recent findings
Metabolic and endocrine adaptations to weight loss that contribute to weight regain involve reduced
energy expenditure, increased insulin sensitivity, and enhanced orexigenic signals. This review summarizes
the impact of carbohydrates on energetic efficiency, partitioning of weight regain as fat and lean mass,
and appetite control. Both the amount and frequency of postprandial glycemia add to body weight
regulation after weight loss and strengthen the concept of glycemic index and glycemic load. In addition,
dietary fiber and slowly or poorly absorbable functional sugars modify gastrointestinal peptides involved in
appetite and metabolic regulation and exert prebiotic effects.
Summary
Current evidence suggests that a low-glycemic load diet with a preference for low-glycemic index foods
and integration of slowly digestible, poorly absorbable carbohydrates may improve weight-loss
maintenance. Future studies should investigate the health benefits of low glycemic functional sweeteners
(e.g., isomaltulose and tagatose).
Keywords
carbohydrates, glycemic index, glycemic load, weight loss, weight regain

INTRODUCTION load diet positively affects body weight regulation

Concerted weight-loss efforts for a limited time
period are usually successful whereas only one out
of every six US adults who has been overweight or
obese has accomplished long-term (>1 year) weight
after weight loss and may be additive to a high
protein content [3] or even contribute to less-fat
mass regain when compared with a high-glycemic
index/or glycemic load diet despite a higher fat
&

maintenance of at least 10% body weight [1]. content [4 ].

Weight-loss maintenance therefore remains the
major challenge of obesity treatment. Dietary strat-
egies for successful weight-loss maintenance have
become increasingly studied and are now replacing
an area of research that focused on dietary advice for
optimized weight loss. Regarding recommendations
for macronutrient composition, the conventional
This review examines how carbohydrates
may impact the metabolic and endocrine adap-
tation to weight loss that contributes to weight
regain. Only a few and methodologically hetero-
geneous studies so far have examined the impact
of glycemic index and/or glycemic load on body
weight regulation during weight loss/regain
& &&

concept for prevention of weight regain is a low-fat
diet that may be beneficial for weight management
because of a low energy density with a high satiety
value that prevents passive overconsumption. A
low-fat diet can theoretically be high in protein that
facilitates weight maintenance by its satiating and
thermogenic effects [2]. A low-fat diet is, however,
usually high in carbohydrate and, therefore, also in
glycemic load (especially if carbohydrates with a
high glycemic index are chosen) and may thus
facilitate a positive energy balance. First results have
shown that a low-glycemic index and/or glycemic
[4 ,5 ,6,7]. We provide a comparative evaluation
of these studies and discuss the drawbacks of
a
Institute of Nutritional Medicine, University Hohenheim, Stuttgart and
b
Institute of Human Nutrition and Food Science, Christian-Albrechts
University of Kiel, Kiel, Germany
Correspondence to Professor Anja Bosy-Westphal, Institut für Ernäh-
rungsmedizin, Universität Hohenheim, Fruhwirthstr. 12, 70593 Stuttgart,
Germany. Tel: +49 (0)711/459 24690; fax: +49 (0)711/459 24699;
e-mail: Anja.Bosy-Westphal@uni-hohenheim.de
Curr Opin Clin Nutr Metab Care 2015, 18:389–394
DOI:10.1097/MCO.0000000000000193

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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Carbohydrates
KEY POINTS
 Both the amount and frequency of postprandial
glycemia add to body weight regulation after weight
loss and strengthen the concept of glycemic index and
glycemic load.
 Dietary fiber and slowly or poorly absorbable
functional sugars modify gastrointestinal peptides
involved in appetite and metabolic regulation and exert
prebiotic effects.
 Future studies should further investigate the benefits of
low glycemic functional sweeteners (e.g., isomaltulose
and tagatose) on energy balance and glucose
homeostasis.
available scientific evidence as well as implications
for future research.
Impact of carbohydrates on weight-loss
maintenance
Weight-loss success is mainly due to the extent of
negative energy balance whereas diet composition
is of minor importance. By contrast, weight regain
is generally slower and may be more affected by the
amount and type of dietary carbohydrates because
the impact of diet composition is not compensated
by the effect of energy balance. In addition, meta-
bolic and endocrine adaptations to weight loss
may render this phase vulnerable to weight regain.
After weight loss, energy expenditure is reduced,
insulin sensitivity is increased, and orexigenic sig-
nals are enhanced [8]. Diet composition can exert
its influence on weight regulation by affecting the
efficiency of fuel utilization and storage, the parti-
tioning of weight regain as fat and lean mass, or
appetite control.
The effect of glycemic index and glycemic load
on energetic efficiency during weight-loss mainten-
ance has been investigated by Ebbeling et al. [7]. In a
controlled three-way crossover design, the authors
compared three different types of weight mainten-
ance diets, each for 4 weeks: a low-fat (20%) high-
glycemic index diet [60% carbohydrate (CHO)] to a
high-fat (40%) low-glycemic index diet (40% CHO)
and a very low carbohydrate diet (10% CHO, 60% fat
and 30% protein). Despite no differences in energy
intake, the decrease in resting energy expenditure
was greatest with the high-glycemic index low-fat
diet (
–200 kcal/day), intermediate with the low-
glycemic index diet (
–170 kcal/day), and least with
the very low-carbohydrate diet (
–140 kcal/day; P
for trend by glycemic load ¼ 0.009). The underlying
390 www.co-clinicalnutrition.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
mechanism for the increase in energetic efficiency
with increasing glycemic load remains unclear as
triiodothyronine was lowest after the very low-
carbohydrate diet. Because the decrease in leptin
with weight loss has been proposed to cause an
increase in metabolic efficiency of skeletal muscle,
the authors speculated that the differences in leptin
sensitivity (reflected by the ratio of energy expendi-
ture to leptin concentration) between the three diets
(very low carbohydrate > high-fat, low-glycemic
index > low-fat, high-glycemic index) could have
been responsible for the observed differences in
energetic efficiency.
Beyond an effect on resting energy expenditure,
there is evidence that a low glycemic load vs. high
glycemic load diet may also increase diet-induced
thermogenesis [9]. However, diets with a lower gly-
cemic load because of low or moderate carbohydrate
content greatly vary in protein content and fatty
acid composition that may also impact the thermic
effect of food [2,10,11].
The effect of glycemic index and glycemic load
on the partitioning of fat and lean mass during
weight-loss maintenance is related to the effect that
a high-carbohydrate diet with a high proportion
of refined carbohydrates will stimulate insulin
secretion and thus inhibit fat oxidation and
promote fat storage. This supposition is supported
by studies showing that, first, improved insulin
sensitivity [12] and reduced insulin secretion [13]
may be potential indicators of successful weight
maintenance, whereas, second, enhanced insulin
secretion (lower glucose concentrations at the end
of an oral glucose tolerance test correlate with pro-
spective weight gain [14], and, third, a preferential
use of carbohydrate for energy production (i.e., a
higher postabsorptive respiratory quotient) were
predictors of weight regain [15]. Consistent with
these findings, 2 weeks of controlled hypercaloric
refeeding of a high-glycemic index vs. a low-glyce-
mic index diet after weight loss led to deterioration
of insulin sensitivity [16] and an impaired basal fat
oxidation especially at a high-carbohydrate intake
&
[4 ]. This impaired fasting fat oxidation was associ-
ated with a higher regain in fat mass and body
weight. Similar results were obtained by an inter-
vention study that used controlled eucaloric dietary
intake during 8 weeks prior to a weight-loss phase
and found that participants who consumed a low
glycemic load diet had 11% less intra-abdominal
fat) than those who consumed the high glycemic
load diet (P < 0.05, adjusted for total fat mass and
&
baseline intra-abdominal fat) [4 ]. Other authors,
however, argue that glycemic index-induced differ-
ences in serum insulin are not sufficient in magni-
tude and/or duration to modify fuel oxidation [17].
Volume 18  Number 4  July 2015

The effect of carbohydrates on appetite control
during weight-loss maintenance is only partly
explained by the concept of glycemic index and/or
glycemic load. First, it seems contradictory that a
primary mechanism by which starches are thought
to regulate satiety and food intake is through their
blood glucose-raising effect whereas previous reviews
have claimed that consumption of high-glycemic
index foods increases hunger and decreases satiety
levels in short-term human intervention studies (for a
review, see [18]). In line with the latter finding, a
lower energy intake is observed with a low-glycemic
index vs. high-glycemic index diet [19,20]. This could
be explained by a prevention of excessive postpran-
dial insulin secretion that leads to a transient appe-
tite-stimulating hypoglycemia. Alternatively, fiber-
related effects independent of glycemic index could
affect appetite control. Fermentable carbohydrates
such as inulin, oligofructose (fructans), as well as
indigestible carbohydrates (dietary fiber and resistant
starch) have been shown to affect appetite-regulating
&
hormones in humans [21 ]. A whole grain barley
kernel product, rich in intrinsic indigestible carbo-
hydrates increased the release of glucagon-like pep-
tide 1 (GLP-1) and reduced subsequent energy intake
&
[21 ]. Moreover, the end products of bacterial fer-
mentation, short-chain fatty acids, have been shown
to regulate expression of gut hormones implicated in
satiety [22].
On the contrary, detrimental effects on appetite
regulation have been found for high intakes of
the low-glycemic index sugar fructose: diminished
suppression of acyl ghrelin in response to fructose
was observed in insulin-sensitive obese compared
with lean adolescents whereas insulin-resistant
obese study participants also had an impaired ghre-
lin suppression to glucose ingestion [23]. Increased
fructose consumption may thus promote hunger
and overeating. These drawbacks of fructose com-
pared with glucose are, however, highly controver-
sial and dose dependent with some results showing
no difference between high-fructose corn syrup and
sucrose on basal and postprandial levels of energy-
regulating hormones (insulin, leptin, and ghrelin)
at normal human consumption levels [24].
In addition to the similar effects on energy-
regulating hormones, short-term overfeeding with
fructose or glucose both contribute to insulin resist-
ance and fatty liver [25]. Recent results in mice have
shown that a slower absorption of simple carbo-
hydrates and reduced postprandial insulin and
glucose-dependent insulinotropic peptide (GIP)
&
levels can prevent liver fat accumulation [26 ]. Also
in patients with type 2 diabetes, ingestion of slowly
absorbed isomaltulose attenuates postprandial
hyperglycemia, decreased plasma concentrations
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Impact of CHO on weight regain Bosy-Westphal and Müller
of insulin, C-peptide, glucagon, and GIP, and
increased GLP-1 that resulted in an increased insu-
&&
lin-to-glucagon ratio compared with sucrose [27 ].
These mechanisms argue in favor of slowly or poorly
absorbable functional sugars such as isomaltulose
(produced by enzymatic rearrangement of the gly-
cosidic bond between glucose and fructose from an
a-1.2 linkage of sucrose to an a-1.6-glycosidic bond)
and tagatose (an L-epimer of D-fructose with an
inversion at C4) that are low-glycemic index, have
prebiotic effects on gut microbiota, and offer a great
potential for improved metabolic and body weight
regulation and therefore deserve greater attention
and further research.
Carbohydrates may affect the dynamics of
weight regain but are unlikely to prevent
regain per se
It is often claimed that maintaining a large weight
loss requires substantial behavioral efforts to over-
come the metabolic and endocrine adaptation to
weight loss that causes a drive to weight regain.
However, although the weight regain-promoting
actions of the discussed mechanisms seem obvious,
they remain largely speculative, as human evidence
demonstrating causal relations between these fac-
tors and weight regain is scarce or lacking [28]. The
main cause of relapse to a positive energy balance
and weight regain is likely to be the lack of
adaptation of energy intake to a lower energy
requirement. After weight loss, reduction in
energy requirement is due to a decrease in resting
energy expenditure, thermic effect of food and
energy expenditure for a certain physical activity
that is partly due to a decrease in body weight, a
decline in activity levels and change in body com-
position, and, to a lesser extent, increased meta-
bolic efficiency [7]. Although the chronic positive
energy balance that led to overweight and obesity is
mainly because of behavioral rather than metabolic
factors, this does not justify blaming relapse into
old habits as a major driver for weight regain. The
failure to adapt energy intake to a suddenly lower
level of energy requirement is a consistent bio-
logical phenomenon that not only applies to
obesity relapse during weight-loss maintenance
but also contributes to weight gain after pregnancy,
increased waist circumference after detraining in
competitive athletes, spontaneous positive energy
balance during physically inactive metabolic ward
conditions, and increase in BMI after spinal cord
injury and smoking cessation. Even the increase in
energy requirement during rapid growth (e.g.,
catch-up growth after a low birth weight and
growth during puberty) may convey a higher risk
www.co-clinicalnutrition.com 391
Carbohydrates

*
35 16

iAUC (mmol/l/14h)
tAUC (mmol/l/7h)
30 14
8 25 12
20 10
8
15
6
10 4
7 5 2
0 0
LGI HGI LGI HGI
Interstitial glucose (mmol/I)

Incremental AUC
4

3 LGI
Total AUC HGI

2
00
00

00

00

00

00

00

00

00

00

0
.0

.0

.0

.0

.0

.0

.0

.0

.0

.0

.0

.0

.0

.0
(h)
0.
1.

2.

3.

4.

5.

6.

7.

8.

9.
10

11

12

13

14

15

16

17

18

19

20

21

22

23
FIGURE 1. Glycemic responses over 24 h for the low-glycemic index (LGI, dark grey symbols) and high-glycemic index
(HGI, light grey symbols) diet groups. Incremental areas under the glucose–response curve during daytime (iAUC-CGMday,
08.00–22.00 h) and total areas under the glucose–response curve during nighttime (tAUC-CGMnight 0–07.00 h) are shown
as an insert. Adapted with permission from [21 ]. &

for the development of obesity. With respect to the peroxisome proliferator activated receptor c, or liver
impact of carbohydrates, there is evidence that X receptor). Both the amount and frequency of
these vulnerable phases benefit from a low-glyce- postprandial glycemia, therefore, add to body
mic index/low-glycemic load diet, for example, weight regulation after weight loss and strengthen
during pregnancy [20,29] and puberty [30]. In the concept of glycemic index and glycemic load.
addition, a lower energy density of food (that can
be achieved by a lower fat and sugar content) also Methods and design of carbohydrate:
ameliorates or even prevents a high spontaneous weight regain studies
energy intake at a low energy requirement under Studies investigating the effect of diet composition
metabolic ward conditions. on energy balance during weight-loss/maintenance
In addition to glycemic index and energy sometimes use body weight as an outcome variable
density, the frequency of high-glycemic index [3] whereas others also investigated fat and fat-free
& &&
carbohydrate intake may be relevant to weight gain mass [4 ,5 ]. Despite methodological difficulties of
and energy partitioning as fat. A hypercaloric diet body composition measurement during unstable
especially with a high sugar content increased liver conditions of weight changes [32], information of
fat and abdominal fat only with high meal fre- changes in fat mass are indispensable for interpret-
quency but not with increasing meal size [31] ation of changes in energy balance. A high-glycemic
suggesting that a continuous flow of nutrients to load diet could theoretically lead to a lower weight
hepatocytes (rather than cycles of fasting and feed- regain that is not due to a less positive energy
ing) stimulates de-novo lipogenesis (e.g., through balance but a higher regain in fat mass with a high
induction of carbohydrate-responsive transcription energetic equivalent. In addition, the composition
factors such as carbohydrate-responsive element- and therefore the amount of weight regain within a
binding protein or insulin-mediated induction certain time period is not independent from the
of sterol regulatory element-binding protein 1c, composition and amount of weight loss [32]. These

392 www.co-clinicalnutrition.com Volume 18  Number 4  July 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.


factors therefore need to be considered when inter-
preting the amount of weight regain.
Studies that controlled dietary intake and pro-
& &&
vided all food to the individuals [4 ,5 ,6] are able to
investigate the impact of diet composition on meta-
bolic and endocrine regulation independent of
energy balance whereas studies that used dietary
advice with ad-libitum energy intake are able to
investigate the impact of carbohydrate quality and
quantity on energy intake. Under this condition,
study center supermarkets providing all food for
the individuals are better suited to assess glycemic
index or glycemic load of the diet compared with self-
reported data from diet records or even food fre-
quency protocols. Biomarkers of glycemic exposure
(such as glycated hemoglobin, fructosamine, gly-
cated albumin, 1,5-anhydroglucitol, advanced glyca-
tion end products, and urinary C-peptide excretion)
are sparsely used in intervention studies among non-
diabetic populations [33]. The responsiveness of
these markers to dietary interventions depends on
the period of exposure as well as glucose variability
and will probably be smaller among nondiabetic
compared with diabetic populations. Today, the
optimal approach to directly assess glycemic
exposure in healthy individuals is continuous glu-
cose monitoring [33]. An example is given in Fig. 1.
Finally, the significance of results may increase
with a careful phenotyping and selection of study
participants. In particular, individuals with hyper-
insulinemia that compensates for insulin resistance
in pregnancy, polycystic ovary syndrome, puberty,
and obesity, and also occurs during weight regain
could benefit from a low-glycemic index diet. But
even in metabolically healthy individuals, bio-
logical variations in insulin secretion because of a
standardized glucose supply occur [34] and may
impact fuel selection.
In conclusion, current evidence suggests that a
low-glycemic load diet with a preference for low-
glycemic index foods and integration of slowly
digestible, poorly absorbable, and fermented carbo-
hydrates may improve weight-loss maintenance.
Future studies should further investigate the health
benefits (glycemic control and weight management)
of low glycemic functional sweeteners (e.g., isomal-
tulose and tagatose).
Acknowledgements
None.
Financial support and sponsorship
This work was funded by a grant of the Germany Ministry
of Education and Research (BMBF 0315681) and the
German Research Foundation (DFG Bo 3296/1-1).
1363-1950 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Impact of CHO on weight regain Bosy-Westphal and Müller
Conflicts of interest
There are no conflicts of interest.
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Volume 18  Number 4  July 2015