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Journal of the American College of Nutrition, Vol. 21, No. 3, 268-274 (2002)
Published by the American College of Nutrition

Original Research

A Comparison of Low-Carbohydrate vs. High-Carbohydrate Diets: Energy Restriction, Nutrient Quality and Correlation to Body Mass Index

Shanthy A. Bowman, PhD and Joseph T. Spence, PhD

1 Nutritionist (S.B.), U.S. Department of Agriculture—Agricultural Research Service, Beltsville Human Nutrition Research Center, Beltsville, Maryland
2 Acting Associate Deputy Administrator (APPVS) (J.T.S.), U.S. Department of Agriculture—Agricultural Research Service, Beltsville Human Nutrition Research Center, Beltsville, Maryland

Address correspondence to: Shanthy A. Bowman, PhD, U.S. Department of Agriculture, Agricultural Research Service, Beltsville Human Nutrition Research Center, 10300, Baltimore Avenue, Building 005, Room 125, BARC-West, Beltsville, MD 20703-2350. E-mail: sbowman{at}rbhnrc.usda.gov


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Objectives: To evaluate free-living adults’ diets that ranged from very low to high amounts of carbohydrate for their energy content, nutritional quality and correlation to Body Mass Index.

Methods: Adults ages 19 years and older, who had complete dietary intake data on day-1 of the USDA’s 1994 to 1996 Continuing Survey of Food Intakes by Individuals (CSFII 1994–1996), were divided into four groups—very low, low, moderate and high carbohydrate—based on the percent total energy from carbohydrate. Mean energy, nutrient, food intakes and Body Mass Index values were compared among the groups. SUDAAN software package was used for the data analysis and pair-wise mean comparisons (p < 0.05).

Results: The high-carbohydrate diet was lower in energy and energy density (number of kilocalories per gram of total amount of food consumed) than the other three diets. Macronutrient composition varied significantly among all the four groups. Nutrient density (amount of nutrient per 1,000 kilocalories of energy consumed) of vitamin A, carotene, vitamin C, folate, calcium, magnesium and iron increased and that of vitamin B12 and zinc decreased with an increase in the percent total energy from carbohydrate. The high-carbohydrate group ate more of low-fat foods, grain products and fruits. This group also had the lowest sodium intake. Adults eating a high-carbohydrate diet are more likely to have Body Mass Index values below 25.

Conclusion: A study of diets of free-living adults in the U.S. showed that diets high in carbohydrate were both energy restrictive and nutritious and may be adopted for successful weight management.

Key words: high-carbohydrate, high fat, weight management, Body Mass Index, obesity


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Obesity is one of the major health-risk factors of today. About 55 percent of adults in the U.S. are either overweight (Body Mass Index from 25 to 30 kg/m2) or obese (Body Mass Index 30 kg/m2 or higher) [1]. The prevalence of obesity increased from 12.0 percent in 1991 to 17.9 percent in 1998, and a steady increase was observed in all the states and across both genders and in all races [2]. Annual obesity-attributable death in U.S. adults is estimated to be more than a quarter-million people [3]. Health professionals, policy makers, the food industry and the public alike devote a considerable amount of time and money toward reducing this obesity epidemic. The prevalence of obesity continues to rise among adults [4] and the direct and indirect cost of obesity in the U.S. is about 10 percent of the national health care budget [5].

Dietary intake is among one of the major determinants of body weight. Energy intakes at levels that result in a positive energy balance contribute toward weight gain [6,7]. Low-fat diets are generally energy restrictive and may reduce the risk of obesity [8–12], while high-fat diets increase this risk [13]. Diets providing between 20 and 30 percent of total energy from fat and 55 to 60 percent energy from complex carbohydrate are considered as balanced diets and are recommended by the Dietary Guidelines [14] and the American Heart Association [15].

Our objectives were to evaluate the diets of a representative sample of U.S. adults that ranged from very-low to high-carbohydrate levels for their energy content, nutritional quality and correlation to Body Mass Index (BMI). We were aware of the limitations of using cross-sectional data to look at the relationship between energy intakes and BMI. However, because dietary habits and food intake patterns change very slowly over time, we assumed that the food and energy intakes of the sampled population remained more or less the same over a substantial period of time prior to the survey. Hence, we think it is appropriate to use the nationwide, food-intake-survey data to look for a correlation between energy intake and BMI.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
USDA’s Continuing Survey of Food Intakes by Individuals 1994–1996 (CSFII 1994–96) data set was used for the study [16]. The CSFII is a nationally-representative, food consumption survey. Dietary intake data were collected on two non-consecutive days, three to ten days apart, through an interviewer-administered 24-hour recall, using a multiple-pass-through technique to reduce under-reporting. Survey instruments were tested in a pilot study and, based on the study results, were revised appropriately. Food coders, field supervisors and interviewers were trained prior to the survey [17]. Overall, day-1 response rate for the survey was 80 percent. Adults ages 19 years and older, who had complete food intake records on the first day of the survey, were included in the study. The sample included 10,014 adults.

Our main interest was to evaluate very-low-carbohydrate and high-carbohydrate diets. We therefore attempted to have a very-low-carbohydrate group at less than 20 percent of total energy from carbohydrate [6]. Because of the low sample size, we used 30 percent or less total energy from carbohydrate as a cut-off value for this group, and this group had a mean intake of 25 percent energy from carbohydrate. The high-carbohydrate level was fixed at 55 percent or more of total energy from carbohydrates as in the case of moderate-fat, balanced diets [6]. The middle range was divided into two groups such that there was about a 10 percent difference between their mean percent energy from carbohydrate.

The sample was divided into four groups based on the percent total energy from carbohydrate: very-low-carbohydrate group, 30 percent or less; low-carbohydrate group, more than 30 percent to 45 percent; moderate-carbohydrate group, more than 45 percent to 55 percent; and high-carbohydrate group, more than 55 percent. There were 420, 2793, 3415, and 3386 adults in the very-low to high-carbohydrate groups, respectively. No gender separation was made, since our preliminary analysis of the four groups showed that both males and females had similar patterns of percentages of total energy intakes from the three macronutrients; moreover, because of the small sample size of the very-low-carbohydrate group, no further division of the groups was made.

There were 228 adults in the study who did not have data on their BMI values. These adults, 152 males and 76 females, were included in the dietary intake analysis, but were excluded from the BMI estimations.

SUDAAN software (Release 8.0.0, 2001, Research Triangle Institute, Research Triangle Park, NC) was used for the estimation of means, standard errors of the means and for the pair-wise comparisons (p < 0.05) among groups. Survey design effects were included in the analysis. Mean energy contribution by food groups was estimated using SAS software [SAS Release 8.2, 1999–2001, Cary, NC]. Survey day-one, full sample weights were used in the data analysis to represent the population studied. Food group definitions in the analysis were the same as that in the CSFII 1994–1996 [18]. Also, total food amount includes the weight in grams of all the foods and all alcoholic and nonalcoholic beverages in the form reported consumed (includes water present in beverages, such as tea, coffee, fruit drinks made from dry mixes, cocoa, and milk drinks; excludes water drunk separately, such as tap and bottled water). Derived water includes water present in foods and beverages consumed, and it does not include water drunk separately. Energy density is the number of kilocalories of energy per gram of food consumed. Moderation in alcohol intake was assigned as no more than 15 grams of alcohol per day for women and no more than 30 grams of alcohol for men [14].

All estimations in this study were based on dietary intake, height, weight and other socio-economic information reported by the respondents.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
The high-carbohydrate diet was more energy restrictive than the other three diets (Table 1). Adults in the high-carbohydrate group consumed 200 to 300 kilocalories less energy than others. All four groups consumed the same total food amount. However, adults in the high-carbohydrate group ate about 200 grams more of total food amount per 1,000 kilocalories of energy intake than the other adults; their diet was low in energy density. A similar pattern was seen in the derived water from the total food amount consumed. The total amount of derived water was the same for all groups, but the high-carbohydrate group had more derived water per 1,000 kilocalories of energy intake than the others.


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  		Table 1. Mean1 Intakes of Energy, Food Amount and Water in a Day by Adults 19 Years and Older, by Percentage Calories from Carbohydrate, CSFII 1994–1996

 
Dietary fiber and carbohydrate intakes increased while protein, total fat and saturated-, monounsaturated- and polyunsaturated-fatty acids intakes decreased from the very-low to high-carbohydrate groups (Table 2). Micronutrient density of the diets, measured as the amount of nutrient per 1,000 kilocalories, increased with an increase in carbohydrate intake for nutrients such as vitamin A, carotene, vitamin C, folate, calcium, magnesium and iron; and it decreased for vitamin B12, zinc and sodium (Table 3).


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  		Table 2. Mean1 Macronutrients Intake2 in a Day by Adults 19 Years and Older, by Percentage Calories from Carbohydrate, CSFII 1994–1996

 

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  		Table 3. Mean1 Micronutrients Intake per 1,000 Kilocalories of Energy Intake in a Day by Adults 19 Years and Older, by Percentage Calories from Carbohydrate, CSFII 1994–1996

 
Adults eating moderate-carbohydrate or high-carbohydrate diets consumed more grains, fruits and fruit juices and milk products. They also consumed less meat, fish and poultry than their counterparts (Table 4). Because of the low intakes of meat, poultry and fish, the high-carbohydrate diets were low in zinc. However, mean zinc intakes of moderate- and high-carbohydrate groups were at fairly adequate levels (11.6 mg and 9.6 mg, respectively), and their mean vitamin B12 intakes were at adequate levels (5.2 mcg and 4.3 mcg, respectively). In spite of their high grain products intake, the high-carbohydrate had the lowest sodium intake.


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  		Table 4. Mean1 Food Intakes and Energy Contribution from Selected2 Food Groups in a Day, by Adults 19 Years and Older, by Percentage Calories from Carbohydrate, CSFII 1994–1996

 
Major food sources of energy varied among the four carbohydrate groups (Table 4). The meat, poultry and fish food group was the highest energy source for adults eating very-low-carbohydrate diets, and the grain products were their second highest energy source. Adults eating low-carbohydrate diets obtained an equal amount of energy from the meat, poultry and fish food group and grain products. This trend reversed for adults eating moderate-carbohydrate or high-carbohydrate diets: grain products were their top energy source followed by the meat, poultry and fish food group.

Adults consuming a high-carbohydrate diet had the lowest total fat intake per 100 grams of all of the food groups containing fat (Table 4). Decreasing trends in the amount of total fat consumed per 100 grams of milk and milk products group (7.5 g, 5.8 g, 4.4 g and 3.0 g, respectively) and meat, poultry and fish group (14.8 g, 12.2 g, 10.3 g, 8.6 g, respectively) were noted from the very-low-carbohydrate to high-carbohydrate group, indicating an increase in the preference for low-fat foods as carbohydrate intakes increased.

Beverages played a significant role in energy contribution. Alcoholic beverages were the third highest energy source for the very-low-carbohydrate group providing 12 percent of total energy, while nonalcoholic beverages were the third highest energy source, providing 11 percent of total energy for the high-carbohydrate group. Intakes of alcoholic beverages decreased manyfold from the very-low-carbohydrate group to the high-carbohydrate group. Our analysis showed that 40 percent of the adults in the very-low-carbohydrate group and 28 percent in the low-carbohydrate group reported drinking alcoholic beverages on the day surveyed (not in tables). Also, 30 percent of adults in the very-low-carbohydrate group and 18 percent in the low-carbohydrate group reported drinking alcohol above the moderation levels recommended by the Dietary Guidelines. Between 37 and 54 percent of adults in all the four groups had carbonated beverages. However, more adults in the moderate- or high-carbohydrate groups (41 percent in each group), and fewer adults (15 percent) in the very-low-carbohydrate group had non-diet, carbonated beverages. Mean intakes of non-diet carbonated beverages increased from 54 grams to 332 grams for very-low-carbohydrate to high-carbohydrate groups, respectively.

A small decreasing trend was noted in the mean BMI values of both males and females (Table 5). Females in the high-carbohydrate group had a lower mean BMI value than the other females. In males, although an apparent decrease in BMI was seen, this difference was not statistically significant. The lack of clear statistical significance among some of the groups could be attributed to the small sample size (hence, large standard errors) of the very-low-carbohydrate group.


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  		Table 5. Mean1 Body Mass Index2 of Adults 19 Years of Age and Older, by Gender and Percentage of Calories from Carbohydrate, CSFII 1994–1996

 
Again, a small but significant trend was seen in the percentages of males and females having BMI values below 25 (Table 6). Percentages of both males and females who had BMI values less than 25 increased from very-low-carbohydrate to high-carbohydrate group.


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  		Table 6. Percent1 Adults by Body Mass Index2 Groups, Gender, and Percentage Calories from Carbohydrate, CSFII 1994–1996

 
The CSFII 1994–1996 data does not include information on energy expended by the adults surveyed, but has information on exercise frequency per week. All four groups had similar physical activity level: about 50 percent of adults in each group exercised rarely, about 25 percent exercised two to four times a week and about 25 percent exercised five or more times a week.

There were 76 percent white Americans, 11 percent African Americans, 9 percent Hispanics, and 4 percent other races in the study. The white Americans were evenly distributed across all four groups (74–76 percent). The African Americans are more likely to be in the very-low-carbohydrate (17 percent) or low-carbohydrate (13 percent) groups. The Hispanics (10 percent) and the other races (5 percent) are more likely to be in the moderate- or high-carbohydrate groups. The age-group distribution was comparable across the four groups. About one-fifth of adults in each of the four groups were between 19 to 29 years of age, about one-fourth between 30 to 39 years of age, about one-third between 40–59 years of age and about one-fifth were 60 years or older.

Adults having high school or less than high school education, living in households with income less than 130 percent of poverty, living in the South or living in rural areas are more likely to have a very-low-carbohydrate diet. Those living in the suburban areas or having four or more years of college education are more likely to have moderate- to high-carbohydrate diets.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
This study showed that the adults who obtained more than 55 percent of total dietary energy from carbohydrates had an energy-restrictive, yet nutritious diet. Different food selection strategies, as discussed below, were adopted by these adults.

First, they were able to achieve energy restriction by choosing foods low in energy density and low in total fat. The low energy density of their diet was partly due to eating foods high in dietary fiber and derived water. Increased water content of foods has been shown to decrease energy intake [19].

The macronutrient composition of the diets of the four groups varied significantly. However, the energy content of the four diets were not influenced by the macronutrient composition of the diets, rather the energy content appeared to be influenced by the energy density of the diet. The high-carbohydrate group, consuming a diet low in energy density, had low energy intake. The other three groups had diets that had similar energy and energy density. Similar findings were observed by Rolls and colleagues [20,21]. Their studies showed that it was the energy density, rather than the macronutrient composition of the diet that affected the total energy intake.

The second strategy for energy-restriction by the high-carbohydrate group was through fat restriction. Total fat intake decreased with an increase in carbohydrate intakes. Adults in the high-carbohydrate group did not avoid milk, meat, poultry and fish products, which are generally perceived to be high in total fat. Instead, they made low-fat food choices from these food groups and other food groups, such as the grain products and total vegetables. This is apparent from the fewer grams of total fat consumed per 100 grams of each of the food groups (Table 4). Individuals consuming a high-carbohydrate diet are more likely to meet the Dietary Guidelines recommendations for both total fat (no more than 30 percent energy from total fat) and saturated fat (less than 10 percent energy from saturated fat).

In addition to achieving energy restriction, the high-carbohydrate group also had a nutritious diet. Their diet consisted of a relatively high proportion of grain products, fruits and vegetables that were rich in many nutrients.

There were other interesting findings in this study. The four groups ate the same total food amount including beverages. However, as discussed earlier, their energy intakes were related to the energy density rather than the total food amount consumed. Other researchers have similar findings where individuals, who ate ad libitum diets varying in energy density, ate the same amount of food by weight, and their total energy intake, therefore, varied directly with the energy density of the diets [22].

Beverages, both alcoholic and nonalcoholic combined, provided between 10 to 14 percent of the total energy for all four groups. Reducing intakes of non-nutritious beverages that are high in calories may be another way to reduce energy intakes without compromising nutritional quality of diets. Especially, adults having alcohol intakes above the moderation levels or having added sugars intakes above the Food Guide Pyramid recommended levels may benefit by limiting intakes of these beverages.

Adults eating a high-carbohydrate diet that provides at least 55 percent of day’s total energy were more likely to have BMI values below 25. The physical activity levels were comparable across the four groups, and the observed lower BMI values, very likely, were not solely due to physical activity levels. The findings of this study support the recommendations of the Dietary Guidelines Advisory Committee on managing one’s weight by including high-fiber, low-fat vegetables, fruits and grains for the prevention of obesity [14].

In the free-living adult population, we observed, diets having less than 30 percent of total energy from carbohydrates were not necessarily energy-restrictive or nutritious when compared to the high-carbohydrate diets. Some of the diet programs that are available to the general public, through books and other means, recommend carbohydrates at levels lower than the mean carbohydrate intake of the very-low-carbohydrate group in our study. It is clear from our analysis that such diets will be further restrictive in many essential micronutrients.


   CONCLUSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
Most people agree that it is important to eat a healthful diet. However, having to make, several times a day, decisions on what foods to eat may pose a challenge to many. This study looking at the dietary choices made at the population level showed that adults whose diets were primarily grain-based and included fruits, vegetables, low-fat dairy foods and low-fat meat, poultry and fish products were both energy-restrictive and nutritious. The study also showed that adults could increase their diet quality by choosing nutritious foods such as fruits and vegetables over caloric, non-nutritious beverages. Fruits and vegetables, in addition, add variety and enjoyment to meals [14].

A diet that includes low-fat foods, grain products and other plant-based foods may be successfully adopted for both weight-loss and weight maintenance. Such diets, in addition to being energy-restrictive, provide many essential micronutrients in adequate or fairly adequate levels.

Dietitians and healthcare professionals who provide weight management guidance and the public who follows different diet regimens that are available through books and other sources of information may find the study results useful.

Received October 19, 2001. Accepted March 25, 2002.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

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