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Journal of the American College of Nutrition, Vol. 21, No. 2, 140S-145S (2002)
Published by the American College of Nutrition

Review

The Influence of Dietary Composition on Energy Intake and Body Weight

Susan B. Roberts, PhD, Megan A. McCrory, PhD and Edward Saltzman, MD

Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Boston, Massachusetts

Address reprint requests to: Susan B. Roberts, PhD, Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, 711 Washington St., Boston, MA 02111. E-mail: sroberts{at}hnrc.tufts.edu


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 REFERENCES
 
We review evidence regarding the influence of dietary fat, fiber, the glycemic index and sugar on energy intake and body weight. Although data from comprehensive long-term studies are lacking, published investigations suggest that the previous focus on lowering dietary fat as a means for promoting negative energy balance has led to an underestimation of the potential role of dietary composition in promoting reductions in energy intake and weight loss. More randomized clinical trials are needed to examine the relative utility of different putative dietary factors in the treatment of obesity.

Key words: diet, energy intake, fat intake, sugar, glycemic index, energy density, body fatness, energy metabolism

Key teaching points:

• The prevalence of obesity is rising, with 63% men and 55% women now overweight or obese.

• Low fat dietary intervention studies have resulted in small weight loss—less than 1 kg on average in studies of up to one year’s duration.

• Interventions increasing dietary fiber have resulted in greater body fat loss, of 1.9 kg on average.

• Interventions that both lower dietary fat and increase fiber appear to be the most effective of carefully tested interventions to date, with weight loss of 3.4 kg on average in studies greater than six months.

• Short-term studies suggest that low glycemic index carbohydrates suppress hunger more effectively than high glycemic index carbohydrates, but there are no long-term intervention studies to examine the effects of lowering the glycemic index on body weight.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
REFERENCES
 
The prevalence of obesity is rising nationally and worldwide [1, 2], and 63 percent of men and 55 percent of women are now overweight or obese in the U.S. [3]. Consumption of Western-style diets and low levels of physical activity have generally been implicated in the worldwide trend of weight gain [4], with a Western diet usually being equated to a high-fat diet. However, Western diets actually differ from traditional diets in several ways, including in dietary fiber content, sugar content and glycemic index. Thus, the effects of different dietary constituents on energy intake and body fatness remain uncertain.

Fat/Energy Density
Current dietary guidelines [5] focus on lowering dietary fat and increasing carbohydrate intake. However, the reported percentage of dietary energy derived from fat in the national diet has fallen steadily over the past 20 years while rates of obesity have risen [6]. This finding suggests, at the least, that factors other than the proportion of dietary energy derived from fat are quantitatively important in the trends that have occurred to date. Nevertheless, dietary fat content can theoretically influence energy intake and hence body weight by several routes. In particular, high-fat foods are usually highly energy dense, and because individuals may tend to eat to maintain a constant volume of food intake, consumption of high-fat foods may encourage passive overeating due to their high energy to volume ratio. In addition, high-fat foods tend to be very palatable [7, 8] and adult consumers typically report that taste is the primary reason they choose to eat certain foods rather than others [9].

The question of whether consumption of high-fat foods leads to increased energy intake and body weight, and whether lower fat diets can promote weight loss, has been studied by many research groups as reviewed elsewhere [10, 11]. Table 1 summarizes studies of energy intake in healthy subjects in which all food was provided for one day to two months duration and energy intake was determined on high and low fat treatments when subjects were allowed to eat ad libitum. Most of the studies summarized in Table 1 did not use treatment and control regimens that were precisely comparable (out of concern to avoid excluding valuable information, only studies with different levels of energy, fiber and protein in the control treatment were considered ineligible for the summary), and thus the results may possibly have been confounded by uncontrolled differences between diets. We therefore differentiate in the table between those studies that approximately controlled for food form (i.e., raw vs. cooked), palatability and variety (three factors known to influence energy intake) and those that were uncontrolled. It can be seen that among the more highly controlled studies, the results obtained were similar to those from the less controlled studies. As shown, energy intakes on the low fat diets averaged 71% (10 days to 2 months) to 84% (1–9 days) of intakes on the control higher-fat regimens. However, it should be noted that studies of energy intake on high and low fat diets that have matched the diets for energy density have found no significant difference in energy intake between groups, suggesting that the effects of dietary fat under usual dietary conditions are mediated by energy density [12].


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  		Table 1. The Effect of a Decrease in Dietary Fat Content on Daily Energy Intake (EI) in Subjects Fed ad libitum in Short-Term (1–9d) or Longer-Term (10d–2mo) Studies

 
A number of longer-term studies have also examined the effects of dietary fat reduction on body weight. Table 2 summarizes those studies that made recommendations to lower dietary fat intake, with mean reported fat intakes in control and intervention populations being 38% and 24% of energy intake, respectively. As shown, virtually all studies showed weight loss in the low fat group compared to the higher fat group. However, it is interesting to note that the changes in body weight observed in the low fat intervention studies are small in absolute terms (0.7–1.0 kg in short-term and long-term studies on average) and also appear small compared to the changes in energy intake noted in Table 1. This comparison suggests that individuals do not lower their energy intake as much when given dietary advice on lowing fat as when they are provided with food of the recommended composition. Consistent with this suggestion, there have been several additional long-term studies of the effects of dietary change on body weight in which low fat diets were provided to subjects and weight loss tended to be high [13–16].


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  		Table 2. The Effect of Dietary Recommendations that Reduce Dietary Fat on Body Weight (BW)

 
Fiber
There is no single accepted definition of dietary fiber, but a physiologically-based description is "plant constituents that are not enzymatically degraded to absorbable subunits in the stomach and small intestine" [17–20]. There are a wide range of plant constituents that fall within this definition, and they can be broadly classified as soluble or insoluble and fermentable or non-fermentable. Fermentability relates to whether the undigested fibers that reach the large intestine are fermented by anaerobic bacteria to yield short-chain fatty acids (which are absorbed and used as an energy source) and gases such as methane and hydrogen. There are several physiological effects of fiber that can be predicted to influence energy regulation as reviewed elsewhere [21]. For example, the energy content of fiber per unit weight food is low; therefore, inclusion of fiber in a diet effectively lowers energy density (especially soluble fibers, because they bind water). High fiber foods also increase gastric distension, and this is suggested to increase sensations of fullness. Fermentable fibers are also thought to increase the production of gut hormones, such as glucagon-like peptide-1 (GLP-1), which are putative satiety signals. Finally, some fibers, in particular the more soluble, fermentable fibers from fruits and vegetables, reduce the overall absorption of fat and protein.

As summarized elsewhere [21], the majority of the intervention studies examining the effects of dietary fiber on energy intake have observed a decrease in intake during consumption of a higher-fiber regimen, with no apparent difference between the effects of soluble versus insoluble fibers and fiber from high-fiber foods versus supplements. Fig. 1 shows the difference in energy intake between control and higher fiber treatments in well controlled studies >2 days duration. Mean energy intake on the higher fiber regimens averaged 90% of that on the control diets in this analysis, and a paired t test showed that energy intake on the higher fiber treatments was significantly lower than on the lower fiber control (p = 0.003).



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  		Fig. 1. Percentage reduction in voluntary energy intake in studies examining the effects of high vs. low fiber diets. Values are means of treatment groups for studies >2 days duration with control group values set to 100. In a paired t test analysis of the group means from individual studies, treatments averaged 90% of controls and were significantly different (p = 0.003). Reprinted with permission from Howarth et al. [21].

 
A summary of the effects of high versus low fiber diets on body weight under ad libitum conditions is shown in Fig. 2. Since there was no apparent difference between different types of fibers (soluble versus insoluble and mixed, and fiber supplements versus high fiber foods), and no difference between longer versus shorter studies, the different studies were combined in this summary. Daily weight loss and total weight loss per study were relatively higher in the ad libitum fed subjects who consumed higher fiber intakes (averaging 1.9 kg totally for a mean study duration of 3.8 months in which an average of 14 g/day of fiber was consumed, p = 0.003), suggesting that the potential effects of fiber on energy intake do in fact translate into changes in body weight. Furthermore, weight loss was more pronounced in those studies that used obese or overweight individuals as subjects rather than non-obese subjects (2.4 kg versus 0.8 kg).



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  		Fig. 2. Rate of weight loss in control and higher fiber treatments. Values are the means of treatment means from ad libitum studies. Differences between the treatments were significantly different by paired t test (p = 0.003). Reprinted with permission from Howarth et al. [21].

 
It is interesting to note that mean weight loss in the subjects participating in the fiber intervention studies was actually greater than the weight loss observed for similar subjects changing from a high fat (38% of energy) to a low fat (24% of energy) energy diet (as detailed above). Moreover, some separate investigations have also tested the effects of diets that are both low in fat and high in fiber [11]. In those studies, mean weight loss was more than three times as great in subjects consuming lower-fat, higher-fiber diets (-3.4 kg in studies = 6 months) than in subjects consuming diets low in fat only (-1.0 kg in studies = 6 months) (p < 0.05) [11]. This amount is greater than the weight loss resulting from diets that are either low in fat or high in fiber, suggesting additive effects of fat and fiber in weight loss regimens.

Glycemic Index
As reviewed elsewhere [22], the glycemic index is a measure of the effect of carbohydrate-containing foods on blood glucose [23]. The glycemic index is usually defined as the area under the glycemic response curve during a two-hour period after consumption of 50 g carbohydrate from a test food, and values are expressed relative to the effect of either white bread or glucose [24, 25]. As such, the glycemic index is considered a specific property of foods and is technically different from the term "glycemic response," which refers to an individual’s change in blood glucose resulting from food ingestion. High glycemic index foods, such as white bread, potatoes and supermarket breakfast cereals, are those that have the highest peak circulating glucose in the two-hour period following food ingestion and the highest area-under-the-curve for the increase in blood glucose above fasting baseline. Because of the intense counterregulatory hormonal response they provoke, consumption of high glycemic index foods can also result in lower circulating blood glucose at the end of the two-hour test period than in the initial fasting baseline [25]. Conversely, low glycemic index foods such as vegetables, legumes and intact grains, are those that cause a lower peak glucose and a smaller area-under-the-curve for the increment in blood glucose in the two-hour postprandial period and have a lower risk of causing relative hypoglycemia (because of the reduced responses of counterregulatory hormones).

In general, high glycemic index foods are those with a high refined carbohydrate content and that are rapidly digested. Specific factors that favor increased glycemic index include: [26–31] high refined carbohydrate content (because fat and protein have minimal effect on blood glucose compared to most carbohydrates); high glucose and/or starch or sucrose content relative to lactose and fructose contents (because the latter sugars yield less glucose, and none in the case of fructose); low soluble fiber content (because soluble fiber forms a gel in the stomach and reduces the rate of gastric emptying and internal digestion and absorption); and finally soft, over-cooked, highly processed or over-ripened food textures (because they are digested more rapidly than foods with greater structural integrity such as firm raw foods, intact grains and discrete harder pieces of food).

There are many short-term studies (lasting for a single meal or a single day) that have addressed the question of whether consumption of low glycemic index foods reduces hunger and/or energy intake relative to consumption of high glycemic index foods as summarized by Roberts [22]. The majority of these studies showed a reduction in subsequent hunger and/or increased satiety following consumption of low glycemic index foods compared to consumption of high glycemic index foods. However, many were not adequately controlled for confounding variables and therefore the results may have been spurious. A summary of the studies that were approximately controlled for energy intake, macronutrient content, energy density and palatability is shown in Fig. 3. In those studies, energy intake averaged 29% more in the meal following consumption of high glycemic index meals or preloads than after consumption of low glycemic index ones, and a paired t test of the study means showed that energy intake after high glycemic index tests was significantly higher (p = 0.005). This analysis strongly suggests that consumption of high glycemic index carbohydrates may promote a short-term increase in energy intake relative to lower glycemic index carbohydrates. However, there is currently little data on the effects of glycemic index on body weight, and such studies are needed to examine whether the effects of glycemic index on energy intake extend to biologically significant periods of time.



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  		Fig. 3. Summary of data from cross-over studies examining the effects of the glycemic index of test meals or preloads on subsequent energy intake. Spitzer and Rodin [34], Rodin [35], Guss et al. [36], Holt and Miller [37], Ludwig et al. [25]. Reprinted with permission from [22].

 
Sugar (Sucrose)
Since taste is one of the most important reasons for individual food choice [9] and sugar is widely considered to be highly palatable, foods with a high-sugar content may be overeaten for reasons associated with taste rather than any metabolic effects of sugar. In addition, however, sugar is a relatively high glycemic index carbohydrate, and as summarized above high glycemic index foods appear to increase energy intake in short-term studies. On theoretical grounds, therefore, sugar can be predicted to promote increased energy intake and weight gain. However, epidemiological studies do not support this suggestion, and in fact typically there are negative associations between sugar consumption and body mass index [32]. One explanation for this apparent conflict may be that overweight individuals may selectively underreport their intake of items perceived to be unhealthy, such as those containing large amounts of sugar. In addition, in practice, very high-sugar diets tend to be low fat diets and there may be hyperphagic effects of both sugar and fat. In support of this suggestion, Raben et al. [33] reported increased energy intake associated with high sugar intake in a 14-day clinical trial comparing a high sugar diet with a high starch diet. Further studies are clearly needed to examine the question of whether high sugar intakes promote long-term weight gain and obesity.

Conclusions
Several dietary constituents and properties, including dietary fat, fiber, sugar and glycemic index, appear to have effects on energy intake in the short-term and may lead to adverse changes in body weight and fatness over time. Most studies have focused on fat or fiber and suggest that fiber may have a greater influence on body weight than fat. In addition, the effects of these two constituents appear to be additive. In other words, diets that are both low in fat and high in fiber appear to promote weight loss more effectively that diets that are either low in fat or high in fiber. Although further data is needed, in particular to assess the long-term effects of different dietary constituents on energy balance, current data suggests that we will enhance the effectiveness of weight loss regimens by emphasizing multiple dietary changes rather than focusing exclusively on dietary fat.


   ACKNOWLEDGMENTS
 
We thank Manjiang Yao and Nancy Howarth for their valuable input. The work was funded with USDA contract 53-3K06-5-10. Contents of this publication do not necessarily reflect the views or policies of the U.S. Department of Agriculture.

Received December 17, 2001.
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