Obesity in adults: Dietary therapy
- George A Bray, MD
George A Bray, MD
- Boyd Professor Emeritus, Pennington Biomedical Research Center/Louisiana State University
- Professor of Medicine Emeritus, Louisiana State University Health Science Center
- Section Editors
- F Xavier Pi-Sunyer, MD, MPH
F Xavier Pi-Sunyer, MD, MPH
- Section Editor — Obesity
- Professor of Medicine
- Columbia University College of Physicians and Surgeons
- Timothy O Lipman, MD
Timothy O Lipman, MD
- Section Editor — Nutrition
- GI-Hepatology-Nutrition Section
- Washington DC Veterans Affairs Medical Center
The optimal management of overweight and obesity requires a combination of diet, exercise, and behavioral modification. In addition, some patients eventually require pharmacologic therapy or bariatric surgery. The risk of overweight to the subject should be evaluated before beginning any treatment program. Selection of treatment can then be made using a risk-benefit assessment (figure 1). The choice of therapy is dependent on several factors including the degree of overweight or obesity and patient preference.
This topic will review the dietary therapy of obesity. Other aspects of treatment are discussed separately. (See "Obesity in adults: Health consequences" and "Obesity in adults: Overview of management" and "Obesity in adults: Drug therapy" and "Obesity in adults: Behavioral therapy".)
GOALS OF WEIGHT LOSS
It is important to set goals when discussing a dietary weight loss program with an individual patient. An initial weight loss goal of 5 to 7 percent of body weight is realistic for most individuals.
●The first goal for any overweight individual is to prevent further weight gain and keep body weight stable (within 5 pounds of its current level).
●The goal of the clinician is to identify and review with the patient a realistic weight loss goal. Most patients have a weight loss goal of 30 percent or more below current weight, which is unrealistic .
- Foster GD, Wadden TA, Vogt RA, Brewer G. What is a reasonable weight loss? Patients' expectations and evaluations of obesity treatment outcomes. J Consult Clin Psychol 1997; 65:79.
- National Institutes of Health, National Heart, Lung, and Blood Institute. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NIH Publication Number 00-4084, October 2000. http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf (Accessed on December 05, 2011).
- Douketis JD, Macie C, Thabane L, Williamson DF. Systematic review of long-term weight loss studies in obese adults: clinical significance and applicability to clinical practice. Int J Obes (Lond) 2005; 29:1153.
- Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346:393.
- Heymsfield SB, Harp JB, Reitman ML, et al. Why do obese patients not lose more weight when treated with low-calorie diets? A mechanistic perspective. Am J Clin Nutr 2007; 85:346.
- Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. J Am Coll Cardiol 2014; 63:2985.
- Hall KD, Sacks G, Chandramohan D, et al. Quantification of the effect of energy imbalance on bodyweight. Lancet 2011; 378:826.
- Trabulsi J, Schoeller DA. Evaluation of dietary assessment instruments against doubly labeled water, a biomarker of habitual energy intake. Am J Physiol Endocrinol Metab 2001; 281:E891.
- Tooze JA, Schoeller DA, Subar AF, et al. Total daily energy expenditure among middle-aged men and women: the OPEN Study. Am J Clin Nutr 2007; 86:382.
- Roberts SB, Rosenberg I. Nutrition and aging: changes in the regulation of energy metabolism with aging. Physiol Rev 2006; 86:651.
- Bouchard C, Tremblay A, Després JP, et al. The response to long-term overfeeding in identical twins. N Engl J Med 1990; 322:1477.
- Lin PH, Proschan MA, Bray GA, et al. Estimation of energy requirements in a controlled feeding trial. Am J Clin Nutr 2003; 77:639.
- Rosenbaum M, Hirsch J, Gallagher DA, Leibel RL. Long-term persistence of adaptive thermogenesis in subjects who have maintained a reduced body weight. Am J Clin Nutr 2008; 88:906.
- Sumithran P, Prendergast LA, Delbridge E, et al. Long-term persistence of hormonal adaptations to weight loss. N Engl J Med 2011; 365:1597.
- Alhassan S, Kim S, Bersamin A, et al. Dietary adherence and weight loss success among overweight women: results from the A TO Z weight loss study. Int J Obes (Lond) 2008; 32:985.
- Wadden TA, Neiberg RH, Wing RR, et al. Four-year weight losses in the Look AHEAD study: factors associated with long-term success. Obesity (Silver Spring) 2011; 19:1987.
- Del Corral P, Chandler-Laney PC, Casazza K, et al. Effect of dietary adherence with or without exercise on weight loss: a mechanistic approach to a global problem. J Clin Endocrinol Metab 2009; 94:1602.
- Pagoto SL, Appelhans BM. A call for an end to the diet debates. JAMA 2013; 310:687.
- Mozaffarian D. Dietary and Policy Priorities for Cardiovascular Disease, Diabetes, and Obesity: A Comprehensive Review. Circulation 2016; 133:187.
- Freedman MR, King J, Kennedy E. Popular diets: a scientific review. Obes Res 2001; 9 Suppl 1:1S.
- Mullin GE. Search for the optimal diet. Nutr Clin Pract 2010; 25:581.
- Flechtner-Mors M, Ditschuneit HH, Johnson TD, et al. Metabolic and weight loss effects of long-term dietary intervention in obese patients: four-year results. Obes Res 2000; 8:399.
- Medline Plus: Diets http://www.nlm.nih.gov/medlineplus/diets.html#cat1 (Accessed on July 19, 2012).
- Phelan S, Liu T, Gorin A, et al. What distinguishes weight-loss maintainers from the treatment-seeking obese? Analysis of environmental, behavioral, and psychosocial variables in diverse populations. Ann Behav Med 2009; 38:94.
- Wing RR, Phelan S. Long-term weight loss maintenance. Am J Clin Nutr 2005; 82:222S.
- Howard BV, Manson JE, Stefanick ML, et al. Low-fat dietary pattern and weight change over 7 years: the Women's Health Initiative Dietary Modification Trial. JAMA 2006; 295:39.
- Nordmann AJ, Nordmann A, Briel M, et al. Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials. Arch Intern Med 2006; 166:285.
- Fung TT, van Dam RM, Hankinson SE, et al. Low-carbohydrate diets and all-cause and cause-specific mortality: two cohort studies. Ann Intern Med 2010; 153:289.
- Paddon-Jones D, Westman E, Mattes RD, et al. Protein, weight management, and satiety. Am J Clin Nutr 2008; 87:1558S.
- Schwingshackl L, Hoffmann G. Long-term effects of low-fat diets either low or high in protein on cardiovascular and metabolic risk factors: a systematic review and meta-analysis. Nutr J 2013; 12:48.
- Wycherley TP, Moran LJ, Clifton PM, et al. Effects of energy-restricted high-protein, low-fat compared with standard-protein, low-fat diets: a meta-analysis of randomized controlled trials. Am J Clin Nutr 2012; 96:1281.
- Claessens M, van Baak MA, Monsheimer S, Saris WH. The effect of a low-fat, high-protein or high-carbohydrate ad libitum diet on weight loss maintenance and metabolic risk factors. Int J Obes (Lond) 2009; 33:296.
- Ince BA, Anderson EJ, Neer RM. Lowering dietary protein to U.S. Recommended dietary allowance levels reduces urinary calcium excretion and bone resorption in young women. J Clin Endocrinol Metab 2004; 89:3801.
- Dawson-Hughes B, Harris SS, Rasmussen H, et al. Effect of dietary protein supplements on calcium excretion in healthy older men and women. J Clin Endocrinol Metab 2004; 89:1169.
- Kerstetter JE, O'Brien KO, Caseria DM, et al. The impact of dietary protein on calcium absorption and kinetic measures of bone turnover in women. J Clin Endocrinol Metab 2005; 90:26.
- Estruch R, Ros E, Salas-Salvadó J, et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013; 368:1279.
- Salas-Salvadó J, Bulló M, Babio N, et al. Reduction in the incidence of type 2 diabetes with the Mediterranean diet: results of the PREDIMED-Reus nutrition intervention randomized trial. Diabetes Care 2011; 34:14.
- Tsai AG, Wadden TA. The evolution of very-low-calorie diets: an update and meta-analysis. Obesity (Silver Spring) 2006; 14:1283.
- Management of obesity by severe caloric restriction, Blackburn GL, Bray GA (Eds), PSG Publishing Co., Littleton, MA 1985.
- Yancy WS Jr, Mayer SB, Coffman CJ, et al. Effect of Allowing Choice of Diet on Weight Loss: A Randomized Trial. Ann Intern Med 2015; 162:805.
- Johnston BC, Kanters S, Bandayrel K, et al. Comparison of weight loss among named diet programs in overweight and obese adults: a meta-analysis. JAMA 2014; 312:923.
- Hession M, Rolland C, Kulkarni U, et al. Systematic review of randomized controlled trials of low-carbohydrate vs. low-fat/low-calorie diets in the management of obesity and its comorbidities. Obes Rev 2009; 10:36.
- Hu T, Mills KT, Yao L, et al. Effects of low-carbohydrate diets versus low-fat diets on metabolic risk factors: a meta-analysis of randomized controlled clinical trials. Am J Epidemiol 2012; 176 Suppl 7:S44.
- Bueno NB, de Melo IS, de Oliveira SL, da Rocha Ataide T. Very-low-carbohydrate ketogenic diet v. low-fat diet for long-term weight loss: a meta-analysis of randomised controlled trials. Br J Nutr 2013; 110:1178.
- Foster GD, Wyatt HR, Hill JO, et al. Weight and metabolic outcomes after 2 years on a low-carbohydrate versus low-fat diet: a randomized trial. Ann Intern Med 2010; 153:147.
- Bazzano LA, Hu T, Reynolds K, et al. Effects of low-carbohydrate and low-fat diets: a randomized trial. Ann Intern Med 2014; 161:309.
- Tobias DK, Chen M, Manson JE, et al. Effect of low-fat diet interventions versus other diet interventions on long-term weight change in adults: a systematic review and meta-analysis. Lancet Diabetes Endocrinol 2015; 3:968.
- Mancini JG, Filion KB, Atallah R, Eisenberg MJ. Systematic Review of the Mediterranean Diet for Long-Term Weight Loss. Am J Med 2016; 129:407.
- Shai I, Schwarzfuchs D, Henkin Y, et al. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med 2008; 359:229.
- Gardner CD, Kiazand A, Alhassan S, et al. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial. JAMA 2007; 297:969.
- Sacks FM, Bray GA, Carey VJ, et al. Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. N Engl J Med 2009; 360:859.
- Corella D, Peloso G, Arnett DK, et al. APOA2, dietary fat, and body mass index: replication of a gene-diet interaction in 3 independent populations. Arch Intern Med 2009; 169:1897.
- Dansinger ML, Gleason JA, Griffith JL, et al. Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial. JAMA 2005; 293:43.
- Yancy WS Jr, Olsen MK, Guyton JR, et al. A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: a randomized, controlled trial. Ann Intern Med 2004; 140:769.
- Foster GD, Wyatt HR, Hill JO, et al. A randomized trial of a low-carbohydrate diet for obesity. N Engl J Med 2003; 348:2082.
- Samaha FF, Iqbal N, Seshadri P, et al. A low-carbohydrate as compared with a low-fat diet in severe obesity. N Engl J Med 2003; 348:2074.
- Stern L, Iqbal N, Seshadri P, et al. The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial. Ann Intern Med 2004; 140:778.
- Ebbeling CB, Leidig MM, Feldman HA, et al. Effects of a low-glycemic load vs low-fat diet in obese young adults: a randomized trial. JAMA 2007; 297:2092.
- Chen TY, Smith W, Rosenstock JL, Lessnau KD. A life-threatening complication of Atkins diet. Lancet 2006; 367:958.
- Larsen TM, Dalskov SM, van Baak M, et al. Diets with high or low protein content and glycemic index for weight-loss maintenance. N Engl J Med 2010; 363:2102.
- Ebbeling CB, Swain JF, Feldman HA, et al. Effects of dietary composition on energy expenditure during weight-loss maintenance. JAMA 2012; 307:2627.
- Colman RJ, Anderson RM, Johnson SC, et al. Caloric restriction delays disease onset and mortality in rhesus monkeys. Science 2009; 325:201.
- Heilbronn LK, Ravussin E. Calorie restriction and aging: review of the literature and implications for studies in humans. Am J Clin Nutr 2003; 78:361.
- Mattison JA, Roth GS, Beasley TM, et al. Impact of caloric restriction on health and survival in rhesus monkeys from the NIA study. Nature 2012; 489:318.
- Redman LM, Ravussin E. Caloric restriction in humans: impact on physiological, psychological, and behavioral outcomes. Antioxid Redox Signal 2011; 14:275.
- Heilbronn LK, de Jonge L, Frisard MI, et al. Effect of 6-month calorie restriction on biomarkers of longevity, metabolic adaptation, and oxidative stress in overweight individuals: a randomized controlled trial. JAMA 2006; 295:1539.
- GOALS OF WEIGHT LOSS
- DIETARY ENERGY
- Rate of weight loss
- Maintenance of weight loss
- TYPES OF DIETS
- Balanced low-calorie diets
- - Portion-controlled diets
- Low-fat diets
- Low-carbohydrate diets
- High-protein diets
- Mediterranean diet
- Very-low-calorie diets
- Choice of diet
- - Weight loss diets
- Side effects
- - Weight maintenance diets
- Role of dietary counseling
- Prolonged caloric restriction and longevity
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS